NLI1 00102711 6 1EBAU'S OFFI^ SOBCEON CEN1 \\ Secti "^2226^ NLM001027418 L' A CLINICAL TEXT-BOOK MEDICAL DIAGNOSIS PHYSICIANS AND STUDENTS BASED ON THE MOST RECENT METHODS OF EXAMINATION BY OSWALD ^IERORDT, M. D. Professor of Medicine at the University of Heidelberg ; Formerly Privat-docent at the University of Leipzig; Later, Professor of Medicine and Director of the Medical Polyclinic at the University o£-4e«e-----------*-- —— rLI>JRARY ci raan BS^SSSBSS ununai DMMMfll ■ hibbbi ■ihibbbi ■ I IIBHWU._ • iinaaBB ■IKIBOZIir MiatnHMBi ■■ BIIIBWMI ■■ BUtBBB I ■■■'Jl'.^lll S5SS BBSS Fig. ii.'—Pseudo-crisis and crisis in pneumonia (Wunderlich). Fig. 12.—Remittent and intermittent fever in catarrhal pneumonia (Wunderlich). time by fever, is defervescing. The defervescence always takes a long series of weeks (compare Fig. 15). Turban supposes that cases of 40° 39° 38° _■■!■■ ■■■■ BBMBMIIBHtBIIBMIBMBBaB ■■s'lSsssssnSsssssssr'S'i'iS'iiS'.'SaS'a! ar a itaaaaBBBMBBBaBaaiiaiiaiiari ■■■•!■■ ■M9IIOBBBBIIHnM««inHIW»aMl! iTisafiBvaBABBiiaBBBBiiiBitiBHaaBBB iicaviBiiaTJBkTBViBiiiBaaaaiKBtmaBBBaB lilll?iB ■■kBBMBiliatiaBBBBIIBIiaBBBBBa 111 ■! ■■fMaaaaai laajanaaaiiBUBBBi ■ ■■■■■■■■■■■■■■ItmiWIIIBBBBU !SSS sasssssissssb: Fig. 13.—Hectic fever in tuberculosis of the lungs. phthisis which defervesce in circular (arc) lines are connected with an infection by streptococci. R. P. T. 90 200 42.0 190 41.5 180 41.0 170 40.5 160 40.0 150 39.5 140 39.0 80 70 60 50 40 20 BBBBSBSSB8 nSBSSBS :::aaBBL IHiB. Fig. 14.—Myelitis transversa. Pyemia caused by decubitus. Male, age 32. 3. Intermittent fever, in a general sense, occurs in combination with remittent fever (see Fig. 12). The hectic fever mentioned above as GENERAL EXAMINATION. °3 ;fl iii::e::::i:: ,- »eeiiiisss::::ss::s3::s::3s -- tssssaazsaBBSBsss sssssaSsasB :■ tssaiiiiiHHCsss aBBsacicsss t::s:t:::;::::::: —ssssssssssssss sssssasss: . aasssasssssss: ::ssss::sl. :k>c:s::::::s::^9s:::::::: issssssssssssssss ::::::::::: 333331333333333:: :aaa::::::a assaaaasa.. 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In a narrower sense, however, we designate as intermittent fever the course of temperature of a special form of malaria. In this there is a continual alternation : between-times, without fe- ver (apyrexia); a quick, high rise, and, after a short time again, a rapid fall of temperature (often below, normal)— " fever paroxysm." Severe chills and perspiration accompany these attacks of fever. The attacks recur with great regularity, either every twenty-four hours (quotidian), or forty-eight hours (tertian), or seventy-two hours (quar- tan). Sometimes the attacks recur one or more hours earlier on successive days (anticipating), or they may recur later each time (postponing). In these forms of fever the diag- nosis is made certain by the fever-curve (see Figs. 16, 18, 19). 64 MEDICAL DIAGNOSIS. 4. Recurrent fever (Fig. 20) only exists as a renewal of a febrile disease or a disease known as relapsing fever. There is an attack of fever very like that of pneumonia, with sharp transitions and very severe sweating, the temperature falling often to 340 or 35° C, and apyrexia; then a relapse after five to eight days, with a chill, followed Day of disease: R. P. T. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 90 200 42.0 190 41.5 80 180 41.0 170 40.5 70 160 40.0 150 39.5 60 140 39.0 130 38.5 50 120 38.0 110 37.5 40 100 37.0 90 36.5 30 80 36.0 70 35.5 20 60 35.0 ,SS8S8B8SBS6S3S8S iiiiii!ii!ir:^jirjficriiwr5:.ig:: Si8BEn8Bi!!.S8BBBB88Sg2^S 8888B8SS8SBB85SS5SS8S8S^8 1 Fig. 17.—Cryptogenetic septico-pyemia, recovery. Female, age 44. by a high continued fever, which, in turn, ends in five or six days by a critical sweat, new apyrexia, fresh relapse; and so over and over again, but each new attack with less fever and of shorter duration. 5. Not infrequently a quite irregular fever will be met with. Its course is such that sometimes one cannot speak of any daily remission ,8 IBI iSBB BBBBB S85SB SSSSB BIBBBB niaaaa maaa mi nil__ ;..:: niiai ■niaaau ■ maaa ■ IIIBBI ■ IBIBBBI 111 Ban ik'.i 41° 40° 39° 38° 37c 36° FIG. 18.—Tertian intermittent fever (Wunderlich). .11 40° 39° 38c 37° 36° SS.:!8§SS!E55S5SS i5ssS»:;s»SSSi unn !■■■■■ •a.BSS BSSBS3 urn ilii!! laiiaBfi'piiaBBBBa ssss^s.is: SsS£bs Ub^bbbSbsbSS Fig. 19.—Quartan intermittent fever (Wunderlich). —at least, the lowest daily temperature comes at a variable hour of the day or night. But this fever may be of diagnostic value. In acute meningitis a continuing irregular movement of the temperature speaks against tuberculosis and against ordinary purulent meningitis, but on the contrary, for epidemic cerebro-spinal meningitis. A pronounced irregular fever in an acute disease generally speaks against any of those diseases which manifest themselves by any typical fever ' GENERAL EX AM/N A TION 65 6. I,ocal Elevation or lowering of the Temperature.— 1. Elevation of the Temperature.—In internal medicine this is seldom of diagnostic aid. We meet it where there is any kind of inflammation which is near the surface, as in surgery. In unilateral pneumonia also a careful measurement shows an elevation of the temperature in the axilla of the affected side. In recent paralysis of any sort the tempera- Day of disease: R. P. T. o 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Fig. 20.—Febris recurrens, with only one relapse. Arrow at a collapse-like crisis. Male, age 44. ture of that side is somewhat higher for a short time; then the tem- perature usually falls. Rare cases of hysteria exhibit a one-sided elevation of temperature with redness of the skin and perspiration. 2. Lowering of the Temperature.—This is the expression of local disturbance of the circulation. In heart-failure, also in collapse and near-approaching death, the extremities and also the nose become cool. Coolness of the affected limb is observed in venous thrombosis, in paralysis of long standing in consequence of diminished venous blood-current, and in arterial embolism and thrombosis. 5 PART III. SPECIAL DIAGNOSIS. CHAPTER IV. EXAMINATION OF THE RESPIRATORY APPARATUS. EXAMINATION OF THE NOSE AND LARYNX. I. The Nose.—In making a local examination of the nose we employ Inspection and sometimes also Palpation. The inspection is external and internal: we look for asymmetry and other deformities and defects, and then at the shape of the nasal entrance [nostril] ; and also we note the quality of the secretions. Symptomatically, important anomalies of the nose are: uniformly swollen nose; the thickening, however, is most marked at the en- trance (scrofulosis); * saddle-nose, caused by syphilitic periostitis, with exfoliation of pieces of bone. The syphilitic coryza (nasal catarrh) of the newly-born is associated with a peculiar snuffling sound.1 As regards the internal inspection, without the aid of instruments we can only examine the entrance into the nose. This only rarely shows characteristic alterations. For the inspection of the deeper parts a reflector and a nasal speculum are necessary. (See the paragraph in the Appendix upon Rhinoscopy.) To the semiology of the affections of the nose belong the following symptoms : foetor ex ore (ozena, ulcerations); occlusion, with respira- tion through the mouth, with obstruction of the nose or in the nasal cavity; speaking through the nose occurs under the same conditions, but also when there is paralysis of the soft palate. This also occurs when there is an abnormal communication between the mouth and nose (cleft palate). Dilatation and motion of the wings of the nose occurs in dyspnea.2 Lastly, there is nose-bleeding [epistaxis], which is usually without any significance. But it may be caused by some severe local or general affection (tumors, aneurysm, deep ulcers, hemophilia, temporary hemor- rhagic disease). Nose-bleeding may be overlooked if it occur in deep sleep or in stupor (in acute infectious diseases), the blood flowing back- ward into the pharynx, through the esophagus, into the stomach. In this case there may be hematemesis, which may lead to an error in diagnosis. Acute muco-purulent and purulent catarrh of the nose is symp- tomatic in measles, diphtheria, and equinia. Chronic catarrh is a 1 See below. 2 See below. 66 EXAMINATION OF THE RESPIRATORY APPARATUS. 6? common symptom of scrofula (in which disease the whole nose is often swollen) and of syphilis. In the former disease there is sometimes an inflammatory thickening of the whole nose, particularly of its lower walls. Inflammation of an acute form, with very foul-smelling and ill-looking secretion, most frequently indicates diphtheria of the nose and pharynx. If it is chronic it may be due to catarrhal or specific ulcers. Among the conditions which particularly demand an examination of the nose, we mention acquired and hereditary syphilis, bronchial asthma, supraorbital neuralgia, hemicrania, certain affections of the eyes and ears. Regarding the further details upon the subjects of this paragraph we refer to the respective special works. As regards palpation of the posterior nares. see works upon Surgery. Palpation of the interior of the nose may be necessary (see works upon Surgery). 2. The I/arynx.—The larynx is examined with reference to its functions (voice, cough, breathing) and the local appearances; the latter include the external and internal examination.1 {a) Function.—The voice is changed in all affections of the larynx. It may be muffled, rough, hoarse, even to the entire loss of voice— " aphonia." In severe diseases it may have a whistling or sibilant (strident) quality: this indicates stenosis of the larynx; or it is very hoarse and deep: this points to deep-seated ulceration. In diseases of the larynx the cough is hoarse, loud, or barking. In extensive destruction and in certain paralyses of the crico-arytenoid muscles cough is either more difficult or is impossible, since the power to close the glottis preceding the cough, as is normally the case, is wanting.2 Breathing is obstructed in all conditions that narrow the larynx, as in inflammation resulting in hypertrophy, in new formations, in scars with contraction. Then there is an inspiratory and expiratory dyspnea,3 and a peculiar noise of stenosis, "stridor laryngeus." In marked stenosis, especially when the thorax is flexible, as in children, there is a drawing in of the lower part of the thorax in front in the region of the insertion of the diaphragm.4 Stenosis only in inspiration, causing inspiratory dyspnea, is ob- served in paralysis of the crico-arytenoid muscles, the dilators of the larynx. Laryngeal stenosis is distinguished from tracheal stenosis at the first glance in that in the former condition the larynx moves up and down simultaneously with each inspiration and expiration, and the neck is stretched to the fullest extent, while in the latter the larynx remains quiet and the head is often somewhat bent forward. (b) Local Examination.—The external examination is made with reference to pain, to deformities revealed to the sight or touch (these are very rare, resulting from destruction by periostitis), and laryngeal fremitus. . Laryngeal fremitus is a trembling of the thyroid cartilage during i See also under Sputum. 2 See Cough 3 gee Dyspnea. * See Anomalies of Respiration. 68 SPECIAL DIAGNOSIS. speech. It is stronger or weaker on one side in unilateral paralysis. It has no special diagnostic value. The Internal Examination.—By great care, and in the case of patients who have themselves under good control, sometimes the entrance to the larynx and the tissues even as far as the glottis can be touched. This method, however, has now little value, since it has been entirely superseded by the examination with the laryngeal mirror, which is the best means of examining the larynx.1 In inflammatory conditions patients complain of pain in speaking, but sometimes, even with severe disturbances, there is no pain; now and then there is dyspnea, especially on exertion. Pain in swallowing in chronic diseases of the larynx frequently indicates serious condi- tions—extension of new formation (carcinoma, tuberculosis) toward the esophagus or destructive suppuration. The leading symptomatic indications of diseases of the larynx with reference to other possible internal diseases are as follows: Acute laryngitis, with manifestations of an acute infectious disease, points especially to measles, croup, and also to small-pox; in chronic laryn- gitis, tuberculosis, syphilis, or a purely local disease of the larynx may be present; constriction by scars suggests, in the first place, syphilis, and also lupus. Of paralyses, paralysis of the recurrent nerve is of special diagnostic importance, since it often arises from pressure upon nerves, especially upon the left side from aneurysm of the aorta, carci- noma of the esophagus, tumors of all kinds in the mediastinum. Cer- tain paralyses indicate hysteria.2 EXAMINATION OF THE LUNGS. Topographical Anatomy of the Thorax. For localizing the surface of the chest with reference to height and depth we make use partly of anatomical prominences and partly (for determining the breadth) of certain local lines which we think of as drawn upon the surface of the thorax. Upon the front side of the thorax are the important anatomical regions : the fossa supraclavicularis (above the clavicle and bounded by the sterno-cleido-mastoid and trapezius muscles) and the fossa in- fraclavicularis. The latter has no distinct lower boundary. We under- stand it as the region immediately below the clavicle, about as far as to the second rib. From the second rib downward we designate the height by the ribs and intercostal spaces, as above the fourth under the fourth rib, the fourth intercostal space. The number of the par- ticular rib is determined by counting from the second rib downward. It is always easy to find this rib: it is in articulation with the sternum exactly where the manubrium and corpus sterni unite, ordinarily form- ing a very slight angle (angulus Ludovici), and this place is plainly to be felt, and often seen, as a cross-line or prominence. We feel for this prominence and find the second rib to be its prolongation. We count the ribs from that downward, feeling obliquely outward as we go down Morenheim's depression [the outer part of the infraclavicular depres- 1 Regarding its use, see the Appendix. 2 gee below EXAMINATION OF THE RESPIRATORY APPARATUS. 69 sion] and the so-called Sibson's furrow (the under border of the pec- toralis major) are sometimes, although not very practically, useful as points for locating internal organs. For determining the breadth the vertical lines now to be mentioned are useful (the subject is supposed to be standing): the middle line, drawn through the sternum; the two sternal lines, drawn parallel along the sides of the sternum; the mammillary lines, drawn through the male nipple; and the parasternal lines, drawn midway between the sternal and the mammillary lines. On the two sides we determine the height by the ribs, which we count in front, and the breadth by the middle axillary line (drawn through the middle of the axilla, the arm being extended sidewise), the anterior and posterior axillary lines (drawn perpendicularly from the points where the pectoralis major and latissimus dorsi muscles leave the thorax, with the arm raised sidewise to the horizontal). Upon the back we name the fossa supraspinata; above that, the suprascapular space, the fossa infraspinata, the interscapular space, between the two scapulae, the infrascapular space, under the shoulder- blades. Exact determination of height is made by counting the ribs, which, however, are difficult to count, especially in fat persons. They can be determined by three methods: {a) By counting the vertebral prominences from the vertebra prominens (the seventh cervical). {b) By counting from the lower angle of the scapula: this over- hangs the seventh rib in the average person when the shoulders hang comfortably and the arms rest against the chest with the forearms folded lightly. {c) By the point of the twelfth rib, which is easily felt (the best way for the lower ribs). Moreover, we have the scapular line, which is drawn upon the two sides of the spine through the lower angle of the scapulae (at the point already mentioned under {b)). It is to be observed that some of the vertical lines are not deter- mined exactly. This is true regarding the mammillary line (always very important) more than any other. In women it is generally very variable. On this account it is always to be thought of as drawn upon a male thorax. But even in the male the nipple is an uncertain point. By much practice the eye is cultivated so as to recognize what is to be regarded as the average location of the nipple in the male, and by this we must always correct the mammillary line. The various attempts to substitute other lines for this one have failed. The designation " infrascapular space " is little used. The expres- sions " right, left, behind, below," correspond to it, and are much to be recommended: behind or below the right, the left, scapula. The Anatomical Boundaries of the Lungs with Reference to the Thorax. In front the lungs reach to the sixth, and behind to the tenth, rib, and are almost everywhere directly in contact with the chest-wall. 70 SPECIAL DIAGNOSIS. They are not in contact with the chest-wall in the neighborhood of the heart nor behind a small portion of the upper part of the sternum. The accompanying figure exhibits the anatomical boundaries of the lungs. They project with their summits into the fossa clavicularis from 3 to 5 cm. above the clavicle, and with their inner anterior borders converging downward, so that behind the angulus Ludovici—not ex- actly behind the middle of the sternum, but a little to the left—they come to lie very closely to each other; then they continue parallel downward to the insertion of the fourth rib. From there the inner border of the right lung proceeds still farther downward to the top of the insertion of the fifth rib, and then gradually bends toward the right, FIG. 21.—Position of the thoracic viscera, of the stomach, and of the liver, from in front. The portions of the heart and liver which are drawn with unbroken hatched lines represent the parietal portions of those organs. The portions that are not in contact with the chest-wall but are covered by the lungs, are represented by broken (clear) hatched lines. The line e f, border of the right lung; gh, border of the left lung; dotted lines (. ) a b and c d the boundaries of the complementary pleural space; i, the boundary between the right upper and middle lobes; k, the boundary between the right middle and lower lobes of the lung; /, boundary between the left upper and lower lobes; w, greater curvature of the stomach (Weil-Luschka). so that it follows along the sixth rib, on the upper border of which it meets the mammillary line. Then it continues approaching the hori- zontal (in the upright posture), so that in the middle axillary line it lies upon the seventh or eighth rib, in the scapular line upon the tenth rib (this location on the dead body is about I cm. higher than in quiet respiration in the living subject). On the left side the border of the lung bends sharply round from the fourth rib to give place to the heart, continues behind the fourth rib as far as the left parasternal line then bends vertically downward, making a small bow which converges toward the right; then, sharply bending again behind the sixth rib so EXAMINATION OF THE RESPIRATORY APPARATUS. J\ as to pass the mammillary line under the sixth rib (hence somewhat lower than on the right side), it passes the axillary line between the seventh and eighth, and the scapular line at the tenth, rib. The boundaries of the lungs are different according to age, as well as in individuals. (See section on Percussion of the Lungs.) The boundaries of the pleural sacs—that is, the lines on which the pleura costalis (sternalis) leaves the wall of the thorax and bends inward —agree in reality with the course of the inner borders of the lung. But along the lower borders of the lungs and at the cardiac concavity the pleural space extends considerably beyond the border of the lungs (in quiet breathing), making the sinus phrenico-costalis and the com- FlG. 22.—Position of the lungs, liver, spleen, and kidneys seen from behind. The liver and spleen are represented by the same hatching as in Fig. 21. a 6, the lower border of the lungs; c d (. . . .), complementary space; i (dotted line) (broken line)< border of the liver; ef (dotted line), boundary between the upper and lower lobes of the lungs; g, boundary between the upper and middle lobes of the right lung (Weil-Luschka). plementary pleural sinus. The size of these corresponds with the form. The largest is the complementary pleural sinus in the two axillary lines. This is there about 10 cm. high. The pleural sinuses are therefore important, since into them extend the lungs at every deep inspiration, and also in the pathological, chronic inflation, emphysema pulmonum; and also—because in them fluid effusions into the pleural cavity ordinarily first accumulate. The under surface of the lungs rests directly upon the diaphragm. The diaphragm in the dead body rises at its highest part, as a dome, about as high as the insertion of the fourth rib, a little higher upon the right than upon the left side. The average situation of the dome of the diaphragm in life, during quiet breathing, is a little lower. 72 SPECIAL DIAGNOSIS. Finally, it is necessary to mention the course of the boundaries of the lobes of the lungs, since they sometimes have an important part in diagnosis: At the back, near the spine, the boundary between the upper and lower lobes is at the height of the lower angle of the scapula; upon the left it gradually slopes forward and outward in such a way that in the axillary line it stands at the fourth rib, and meets the lower border of the lung (that is, at the sixth rib) in the mammillary line. On the right side the boundary-line divides near the outer border of the scapula into two diverging lines—the line between the upper and middle lobes and that between the middle and lower lobes. The former proceeds at first behind the third rib, and terminates at the inner border of the lung at the insertion of the fourth rib ; the latter meets the lower border of the lung somewhat within the mammillary line, and therefore behind the sixth rib. Hence, in front upon the right side we have the upper lobe about at the third intercostal space; from there downward, really the middle lobe; in front on the left side, for the whole distance, we really have the upper lobe; on the right side we have the middle lobe above and the lower lobe below; on the left side we have the lower lobe; behind we have only the apices, formed by the upper lobes; all the rest is lower lobe. Inspection of the Thorax. The examination of the thoracic organs must always begin with the inspection of the thorax. Nothing is more faulty than to take up some other method of examination first. Inspection of the thorax is impor- tant because a very large number of the diseases of the lungs and pleura manifest themselves in the form of the chest-cavity and a change of the respiration. Certain diseases of the internal organs have a causal relation to changes in the form of the thorax. In other cases, as it appears, a given form of thorax accompanies a " disposi- tion " of the lungs to certain diseases (emphysema, phthisis). It is very probable, although it is difficult positively to establish, that some- times the thorax by its form either causes or favors the development of the given disease. Moreover, we know that there are deformities of the chest which in other ways injure or render useless the thoracic organs; there are such also as have no influence upon the lungs or heart. Method of Procedure.—During inspection (as in all examinations of the thorax) attention must be given to having the patient straight, but without undue muscular tension. The light should fall symmetrically upon the front or back, whichever is under examination; the eyes of the examiner should, if possible, be directly before the middle line of the body. The general structure of the thorax (and neck) should first be considered, next possible peculiarities, then the motions of respira- tion, first during quiet, then deeper, respiration. i. Normal Form of Thorax and Normal Respiration.__In a well-constructed thorax we expect, first, perfect symmetry. However this is departed from almost always normally, in that there is a verv slight curvature of the dorsal vertebrae toward the right. Moreover the clavicular depressions may be only slightly indicated; the angulus EXAMINATION OF THE RESPIRATORY APPARATUS. 73 Ludovici [also called the angle of Louis] (the angle formed by the junction of the manubrium and corpus sterni) may just be recogniz- able; the true ribs should so leave the sternum that from the top downward there is increasing obliquity, making the angle formed by .the two opposite bendings of the ribs, " the epigastric angle," almost a right angle. The thorax should be well developed; the scapulae in the upright position should lie flat upon it; the intercostal spaces should be visible only at the lower ribs ; finally, the dimensions of the chest and the size of the body should have a certain relation to each other. Very seldom does the normal thorax correspond to this ideal, and there are many departures from it in persons who are perfectly sound. Some " physiological" departures may be mentioned: a slight asym- metry in a gradually-acquired spinal curvature or a deformity of the ribs, self-established; further, a peculiar form of thorax, where the upper part is somewhat shallow, but the lower of increasing depth, so that the lower aperture of the thorax is very large; also more marked angle of Louis (Braune); again, in a shorter thorax, a more obtuse epigastric angle may sometimes be observed in healthy persons (hence also without signs of emphysema).1 The supraclavicular depressions are often both deepened, with the apices of the lungs entirely normal (unequal deepening of them is, however, very suspicious of tubercu- losis) ;2 single ribs, more frequently the second, third, also the fourth, on account of greater curvature sometimes project more in front; on the other hand, the lower ribs will often be found pressed into the side and from there flattened forward; and other variations. The boundary between the unsymmetrical and the pathological form of chest is much confused; it can only be recognized in the individual case by attention to the location and function of the thoracic organs. Normal breathing takes place in this wise: inspiration only is active —that is, is accomplished by muscular action; expiration, on the con- trary, is produced wholly by the elasticity of the lungs, the elasticity and the weight of the chest-wall, and the pressure of the abdominal organs upon the diaphragm. The number of respirations to the minute in the new-born is about 44; at five years, about 26; from the twen- tieth year, about 16 to 20. It is very easily influenced by a number of conditions : in sitting and standing it is somewhat higher than in lying; it is increased by bodily activity and psychical impressions. Therefore it can only be determined during perfect quiet, with the attention with- drawn from the examiner, or during sleep. For counting it, it is generally most advantageous to lay the hand lightly upon the chest (or upon the epigastrium). The breathing is generally regular, and the single breaths are of equal strength; but under the influence of the slightest psychical dis- turbance they easily become irregular and unequal. Many persons of sound health, as snorers in sleep, often breathe irregularly or unequally deep. Breathing is either exactly or very nearly symmetrical, though the left side frequently inclines to breathe a trifle stronger. The inspiratory enlargement of the thorax is occasioned by the ele- vation of the ribs and the sternum and the simultaneous drawing of the former upward and outward (intercostales externi and interni muscles 1 See below. 2 See below- 74 SPECIAL DIAGNOSIS. —" costal breathing"); moreover, by the contraction of the diaphragm, and hence flattening of its dome. The latter movement at the same time draws down the intestines, and so with every inspiration the whole anterior wall of the abdomen projects, but especially the epi- gastrium (" diaphragmatic," or abdominal, breathing). The combina- tion of costal and diaphragmatic breathing varies in the two sexes: in the male the latter, and in the female the former, preponderates. But in aged females with firm thoracic walls diaphragmatic breath- ing increases; while, on the other hand, male as well as female children incline to the costal type of breathing. From this it seems that the degree of flexibility of the thorax influences the kind of breathing. In the costal breathing of women, even in quiet respiration, the scaleni muscles (elevators of the first and second ribs) take a part, while in men these muscles belong to the auxiliary muscles of respi- ration.1 Diaphragmatic Phenomenon (Litten).—This peculiar and very strik- ing phenomenon can only be observed by keeping rather closely to the proceeding which the discoverer has indicated: The person to be examined should be undressed to the middle of the abdomen, and then should lie down as nearly as possible in a hori- zontal position, with the feet toward the light. The room should be lighted only from one side. In the daytime, therefore, one should select a room with only one window, or, if there be more than one, all but one must be darkened. The patient is asked to breathe deeply, and the breathing must be diaphragmatic. The attention of the ob- server is directed to that part of the thorax which is below the fifth rib. The observer stands about one and a half to three steps from the side of the person examined or from a position midway between the side and feet. In most people, but not at all in stout persons, a shadow-like line ascends and descends with each respiration. This line is only present in the intercostal spaces, but as it crosses the ribs diagonally it appears in several intercostal spaces at the same time, and moves regu- larly up and down, and, in spite of the interruption by the ribs, it gives the impression of a continuous line. It is seen most distinctly near the anterior axillary line between the seventh and ninth ribs. In some people it can be followed from there far to the front and even round to the back. From the illumination necessary to observe this phenom- enon we conclude that the skin slopes toward the head. This sloping must of course be connected with diaphragmatic respiration or with the displacement of the edge of the lungs, the more so as it always coin- cides exactly with the boundary of the lungs as made out by percus- sion. The falling off of the surface of the skin taking place from below upward, as we have mentioned above, it is therefore probable that it corresponds, as Litten thinks, with the separation of the diaphragm from the wall of the thorax. It is impossible to see in this phenom- enon that portion of the edge of the lungs which goes down into the complementary space, for this would produce a slope from above downward. The value of the phenomenon for the diagnosis of the extent of 1 See Auxiliary Respiratory Muscles. EXAMINATION OF THE RESPIRATORY APPARATUS. 75 diaphragmatic respiration is, in my opinion, impaired by the fact that the phenomenon can be observed even in healthy people, frequently in only a small part—namely, that which is directed from above down- ward. There are not many cases in which it is seen moving up and down for six or seven centimeters, as is stated by Litten. If on one side the diaphragm does not move, and if the diaphragm is forced downward, the phenomenon will not be seen on that side, and conse- quently it is not observed in paralysis of the diaphragm and when there is considerable exudation and transudation of the pleura in pneumo- thorax, in pneumonia of the lower lobes, and also sometimes in sub- phrenic peritonitis. But it is well known that the last-named disease sometimes does not interfere with the contractions of the diaphragm, and in such a case the existence of the diaphragmatic phenomenon would decide the differential diagnosis against exudation in the pleura. But I have never yet seen such a case. 2. Pathological Forms of Thorax.—{a) The Inflated or Em- physematous Thorax.—This refers to a chronic symmetrical expan- sion in all directions, conforming somewhat to the form of the chest during inspiration (the inspiratory position). The antero-posterior (the sterno-vertebral) diameter is increased. In many cases it appears as if the thorax became enlarged, especially at about the height of the mid- dle of the sternum, making a barrel-shaped chest; however, this may be entirely wanting. The ribs are generally strong, and are at right angles to the sternum, hence the epigastric angle is larger than nor- mal ; the thorax is generally short. Frequently the angle of Louis is very prominent. The supraclavicular depressions may vary very much : sometimes they are deepened; again, shallow or even projecting like pillows (the latter condition obtaining in emphysema of the upper part of the lungs). The lower intercostal spaces are sometimes drawn in during inspiration (inspiratory drawing-in).1 In the emphysematous thorax the breathing is so changed that the expiration is both slower and imperfect in consequence of the dimin- ished elasticity of the lungs; it is prolonged, and in marked emphy- sema it is assisted by muscular action, especially by the transversahs abdominis and the quadratus lumborum. We can then plainly see the abdominal wall energetically flattened, and we are directly impressed with the idea that the thorax is forcibly expanded. But the inspiration is also altered in consequence of the rigidity of the chest-wall; ordinary costal breathing is wanting ; it is very imperfect; and in its place we notice that the front of the chest, as a whole, has been drawn up by the powerful action of the sterno-cleido-mastoidei muscles Conse- quently, in emphysema we have the breathing rendered difficult; in severe cases it may become so to a high degree. _ The typical emphysematous thorax points almost with certainty to emphysema, and hence its name; however, we must guard against the mistake of calling every short chest an emphysematous one. On he contrary, also, we not infrequently find a general emphysema of the lungs in a chest that has no trace of the "emphysematous form. Active expiration, expiratory dyspnea, is much more characteristic , „ , , o 2 See Dyspnea. 1 See below, p. 87. 70 SPECIAL DIAGNOSIS. than the form of the thorax; besides emphysema, it exists in no other condition except certain diseases of the larynx.1 {b) The Paralytic or Phthisical Thorax.—This is the direct oppo- site of the preceding: it is flat, especially in the upper part; is often also narrow; the intercostal spaces are wide; the ribs are generally delicate, are sharply inclined downward from the sternum, and hence must be bent at a sharp angle again in order to come back to the vertebrae. This sloping from the sternum makes the epigastric angle very sharp; the chest, as a whole, chiefly in consequence of the course of the ribs, is long. The angle of Louis is often very marked. The depressions are generally deep. The shoulder-blades frequently stand out like wings. Quiet breathing may be almost normal, but on exertion it is generally immediately very much increased in frequency; it is shallow; even in women the costal type is often wanting, especially at the upper part of the chest. This form of chest corresponds with that of tuberculosis. A well- marked paralytic thorax, except where phthisis of the lungs has early developed, is very infrequently seen ; but yet this disease occurs very often where the phthisical thorax is wholly absent—indeed, with an emphysematous thorax. In a paralytic thorax, with phthisis already developed, by means of the latter the form of the thorax and the breathing will become essentially and variously changed.2 But one must be very careful not to conclude that a thorax narrow from great emaciation, and especially one that appears flat, is a para- lytic one. For example, a beginner is apt to find that a patient conva- lescent from typhoid fever has a paralytic chest. Strictly speaking also, every plain or flattened thorax is not to be called a paralytic one. Moreover, emaciation and flattening of the upper parts of the chest in cases of developed phthisis frequently render the thorax paralytic, which it originally was not. {c) One-sided expansion of the thorax, a relatively infrequent affection, occurs in disease or functional loss of the opposite lung. The dilated side is then the seat of the so-called " vicarious emphysema" of the lung. This is distinguished from true emphysema by the absence of expiratory dyspnea. The dilated side is much more frequently the diseased one. The widening of the chest-cavity is more plainly seen from the front than from behind. Very frequently the mamma and the scapula are further removed from the median line than upon the normal side. The inter- costal spaces are level or are projecting; in contrast with this, the dis- eased side drags after the other—that is, in inspiration it rises later and less than the sound side, and it may even not rise at all. Hence the spinal column is sometimes bent toward the diseased side. Marked expansion is met with in pneumothorax and in extensive pleuritic exudation, while the development of the latter usually first manifests itself by expansion and lagging behind at the posterior and lower part of the chest. A very slight expansion of one-half of the chest is, moreover, sometimes seen in croupous pneumonia of the whole of the affected lung. 1 See Dyspnea. 2 See above under (a) and below under (d). EXAMINATION OF THE RESPIRATORY APPARATUS. 77 Circumscribed forward expansion of the chest occurs especially with tumors of the pleura, and is sometimes humped, and again uniform; empyema which inclines to breaking through pushes the affected region prominently forward, and at the same time the skin is generally edematous. Encapsulated pleuritic exudations or circum- scribed pneumothorax seldom causes expansion, yet the first cause a smoothing out of the neighboring intercostal spaces, besides lagging behind. Local projections, moreover, sometimes occur from inflam- matory affections or neoplasms of the ribs or the subcutaneous cellular tissue. Local expansions of the thorax are seen in cases of enlargement of other organs. The cardiac region may be bulged out in enlargement of the heart or distention of the pericardium;l a marked enlargement of the liver may press out the lower ribs on the right side, and enlarge- ment of the spleen on the left; and sometimes, especially in children, a very marked expansion of the whole lower part of the thorax, an en- largement of the lower aperture of the chest, is observed in cases of considerable expansion of the whole or the upper part of the abdomen (meteorismus, ascites, peritonitis, tumors). Then the upper part of the chest seems quite small in comparison with the lower part; the whole trunk is hence shaped like a bee. From the drawing up of the dia- phragm there results interference with diaphragmatic breathing, and generally there is severe dyspnea. The extent to which the thoracic wall is driven forward, if caused by pleuritic exudation, depends to a large extent upon the degree of flexibility of the thorax. If the wall is soft, as is the case with chil- dren, the expansion is very pronounced; if rigid, as in subjects of emphysema, sometimes a very large pleuritic exudate causes no noticeable expansion. Therefore, while we expect in general that an extensive pleuritic exudate will manifest itself by an enlargement of the affected side of the chest, yet where the walls are rigid we must not conclude from the absence of expansion that there is no exudate. (d) Drawing-in or Shrinking of One Side.—This is seen more or less frequently as a symmetrical drawing-in of the whole side, so that the affected side is altogether smaller than the other; the ribs are close together, and in the lower part they may even overlap like shingles on a roof. 'The shoulder of that side hangs down; the mamma and scapula are nearer the median line. The spinal column is curved with its convexity toward the healthy side; hence the whole carriage is affected. There is diminished breathing or no breathing at all on the side drawn in ; on the healthy side there develops a vicarious emphy- sema. This condition is observed in recovery from extensive pleuritic exudations and in long-continued contraction of the lungs. In pleurisy it is the loss of elasticity and thickening of the pleura, with adhesions of pleural surfaces, in shrinking of the lungs, and the development of connective tissue in the lungs, which not alone hinder the lungs from following the inspiratory expansion of the thorax, but from the tendency to contract, as in scars of the skin, draws in the chest-wall. This inward traction, however, does not concern the thorax alone: the mediastinum, heart, and diaphragm are pulled 1 See under Examination of the Heart. 78 SPECIAL DIAGNOSIS. toward the sunken side. Hence there is displacement of the heart toward the diseased side and the diaphragm is high in the chest. More frequently there is an unequal degree or a partial shrinking on the affected side; with it also is always connected a more or less marked lagging. It is most frequently observed above in front, here sometimes noticeable at the first commencement as a deepening of the supraclavicular depression (an important symptom of contraction of the apex of the lung from tuberculosis). Again, a partial drawing-in is often seen, most frequently low down posteriorly, after the disap- pearance of a small pleuritic exudate. But there may be shrinking of any part of the chest-wall, as after gangrene or abscesses of the lungs. One must be careful not to confound a deformity of the chest from disease of the thoracic organs with deformities that are dependent on a primary bending of the spine and thorax. Concerning these see the following section. A repaired fracture of the ribs may also cause deformity; a fracture of the clavicle which has healed with an angle forward may deepen the supra- and infraclavicular depressions, and so deceive one; one- sided defect or atrophy of the pectoralis major of course flattens that side. All of these cases may be excluded by a more careful exami- nation. {e) Alterations of the Form of the Chest by Primary Deformity of the Skeleton.—Kyphosis, or bending backward, and scoliosis, the bending sidewise, of the spine, but, still more, the combination of both, kyphoscoliosis, sometimes occasion deformities of the chest that are enor- mous. Most frequently one side is smaller in front, while the other side appears to be enlarged; and the picture of one-sided contraction of pleura or lung is more complete from the dragging-after of the smaller side. In consequence of a peculiar twist of the spine and its effect upon the course of the ribs the back is generally very crooked. This is spoken of more particularly in works upon surgery. The organs of the chest are almost always displaced from their normal position. The lungs are very much impaired in their function. Such patients become short-breathed on the slightest exertion. In diseases of the thoracic organs, and also in acute infectious diseases, these patients are exposed to greater risk than others. Whether in such cases we have to deal really with a primary deformity of the chest or with a contraction of the lung or pleura is generally made clear by the examination of the spine. Sometimes, however, a very careful examination of the skeleton and of the thoracic organs is necessary to answer this question • and in some cases of long-existing deformity even this differential diagnosis may be impossible. The distinction of the different kinds of spinal curvature and their origin belongs to surgery. Rachitis is frequently the cause of such deformities, but it may also cause all other possible bendings of the chest. Of these, especially characteristic are—I. The rachitic chest, a thickening of the point of transition from the cartilage to the bony ribs. The several prominences arising from it form on both sides of the sternum a line passing as an arch outward and downward. 2. The pigeon-chest. The chest seems to be compressed sidewise and pressed forward. The ribs run sharply EXAMINATION OF THE RESPIRATORY APPARATUS. 79 backward from the front, so that the sternum stands forward like the keel of a ship, the sternovertebral measurement being much increased 3. A circular drawing-in in the neighborhood of the costal attachment of the diaphragm and above it. This retraction is in part directly pro- duced by the diaphragm, because the softened ribs do not offer suf- ficient resistance to its contractions. The retraction, however partly results from the circumstance that the thorax sinks in just above the point of insertion of the diaphragm in consequence of the inspiratory lowering of the internal pressure. If dyspnea exists, and consequently increased action of the diaphragm, the retractions are increased. Funnel-breast (Fig. 23).—This deformity consists in a sinking-in of Fig. 23.—Funnel-breast (Ebstein). the sternum, especially of the lower portion of it; it may be very con- siderable (as much as 7 cm.). The affection is generally congenital, and, according to our experience, in very marked cases it may prove a hindrance to respiration. Shoemakers' breast exhibits a sort of acquired funnel-breast, caused by pressure of tools against the lower part of the sternum and the xiphoid cartilage; the depression never becomes very great, and involves only the cartilage; it has no pathological signif- icance. According to recent experience, the funnel-breast sometimes is observed in several branches of a family. In individual cases it occurs as a sign of degeneration with other errors of development, or asso- ciated with neuropathic or psychopathic disease or hereditary taint. 3. Anomalies of Respiration.—In the preceding section the anomalies of breathing which accompany the several pathological forms of thorax have been briefly referred to. But these require a further separate description. In giving this it will not be possible to avoid a partial repetition of what has already been said. 8o SPECIAL DIAGNOSIS. {a) Anomalies of the Manner of Breathing.—The type of breath- ing which, as has been mentioned above, in the normal human being is typically different in the two sexes, and is denominated costal and costo-abdominal, may be influenced by a number of different path- ological conditions: i. The activity of the diaphragm, from some cause or other, may be restricted or entirely stopped; it may then be replaced by increased thoracic breathing; this causes the costal type peculiar to women to be still more prominent, while the male type is reversed; instead of the abdominal predominating, the costal becomes predominant or entirely prevails—that is, may take on the female type. Such a restriction or prevention of the action of the diaphragm is occasioned by pain or mechanical restraint, or by weakness or paralysis of the diaphragm. Such is the action of all inflammations of the abdominal or pleural cavities in case they involve the corresponding serous covering of the diaphragm, markedly impairing diaphragmatic breathing. They often act so because they are painful; but also some- times, especially in inflammation of the diaphragmatic peritoneum, actual paralysis of the diaphragm quickly develops, which is recog- nized by the entire disappearance of abdominal breathing.1 This takes place quite commonly in diffuse peritonitis; it is, however, also some- times the only symptom of a beginning local " subphrenic " peritonitis. Marked distention of the abdomen by tumors, fluid, and accumulations of gas in the intestines hinders diaphragmatic breathing in a high degree. Finally, there occurs paralysis of the diaphragm in organic diseases of the nervous system (bulbar paralysis, neuritis of the phrenic nerve in the various forms of multiple neuritis), as well as a manifestation of functional neurosis (hysteria). The action of the diaphragm is recognized, as has frequently been mentioned, by the protrusion of the epigastrium during inspiration. Of course this does not take place when there is no contraction. In complete paralysis the diaphragm is sometimes even completely sucked into the thorax; in hysteria, during inspiration, the epigastrium some- times sinks in extraordinarily deep. One-sided failure of action of the diaphragm may also occasionally be made out.2 2. But sometimes, also, hindered thoracic breathing may be replaced by increased diaphragmatic breathing; hence in such a case, if the patient is a female, the type of breathing is changed—that is, abdominal breathing predominates instead of costal. Therefore, in very rigid thorax (emphysema), sometimes also in women, diaphragmatic breathing predominates. Here belong paralysis of the muscles of inspiration (bulbar paralysis) and myositis ossificans (rare), since the latter causes a rigid condition of the thorax. A disease of the skin at present well known, but rare, scleroderma, may, if located upon the thorax, also entirely abolish thoracic breathing. It has been shown above, under Emphysematous Thorax, how in lieu of the peculiar costal breathing, this may in part be replaced by the movement of the thorax as a whole by the (auxiliary) muscles__ the sterno-cleido-mastoidei.3 3. Asymmetry of breathing, which is occasioned as follows: the 1 See p. 74. 2 See Palpation. 3 See i^elow. EXAMINATION OF THE RESPIRATORY APPARATUS. 81 whole side or the upper or lower part of one side either (very rarely plainly) expands somewhat later than the opposite side or (most fre- quently) expands less strongly or not at all; which condition has already been mentioned several times. Such a lagging may be caused by a unilateral painful affection of any kind; moreover, by all diseases of the thoracic organs which inter- fere with respiration upon one side. This " lagging behind " is a valu- able symptom, especially in phthisis (lagging in the infraclavicular depression), also in the beginning of pneumonia and pleurisy, when other symptoms are wanting.1 {b) Anomalies of Breathing as Regards Frequency and Rhythm. —Diminished frequency of breathing may take place in all severe dis- eases of the brain and its meninges, hence in large hemorrhages, tumors, etc. and in all forms of meningitis; thereby exists always more or less dulness of intellect; the slowness of breathing may sometimes pass into the Cheyne-Stokes respiration.2 Further, in acute infectious diseases with marked mental dulness the respiration may be slower; finally, it is generally so in the death-agony. A very important form of diminished frequency of respiration is observed with stenosis of the upper air-passage; this belongs in the section on Dyspnea. Increased frequency of respiration as a patho- logical manifestation belongs, without exception, to a large group, which will also be discussed in the next section. It has already been mentioned that we meet with temporary irregu- larity of breathing in healthy persons. It is of pathological, and gen- erally of grave, import in all cases of marked mental dulness (as in apoplectic, uremic, and the coma of severe typhus), and very especially in the death-agony. Forms of Periodic Respiration.— i. Cheyne-Stokes Respiration.—This is a kind of respiration in which, in pronounced cases, a group of respirations regularly alternates with a more or less prolonged pause of respiration, or apnea. The transition, however, from one state to the other is effected gradually, the period of respiration beginning and ending with shallow breathing. The patients, who in most cases are in a state of stupor, impress the observer by the circumstance that with regular pauses they make a few deep snorting or snoring, or perhaps sighing, respirations. If one observes a little closer, he sees that these deep respirations are followed by a few which become weaker and weaker, and then the respirations cease altogether. After a certain pause there is a short, scarcely perceptible respiration. This is followed immediately by a somewhat deeper one, and progressively the respira- tions become abnormal in depth, from which they slowly decline till a period of apnea is again reached. The pause in respiration may last a minute, and exceptionally even longer. [The translator recently observed a case following uremic convulsions in which the pause lasted ninety seconds.] The number of respirations in one period varies. Most frequently there are eight to twelve, which follow each other in about normal celerity, but at the beginning and end of the period of respiration they are sometimes somewhat slower. Occasion- 1 See Palpation of the Thorax. 2 See below. 82 SPECIAL DIAGNOSIS. ally there are, besides, some secondary symptoms : regular contraction of the pupils during apnea, and dilatation of them in the height of respiration ; retardation of the pulse during apnea; isolated con- traction of muscles at the end of apnea. Sahli has observed that patients become cyanotic at the beginning of respiration, and that the cyanosis increases till the height of the respiration is reached, which corresponds with the conduct of the pupils. Fi- nally, we and also others have here and there observed a peri- odic change in the state of con- sciousness corresponding exactly with the respiration : patients al- ready somewhat stupid become entirely unconscious during the period of apnea, and with the beginning and deepening of res- piration they regularly revive, look around, and even speak. Besides the perfect form of Cheyne-Stokes respiration, just described, there are also some less striking forms. It is not necessary that it comes to an audible deep breathing, or even to an abnormal depth of respi- ration ; or the period of apnea may be very short. The apnea may also be missing, in such a manner that only deep and more superficial breathing alternates, in regular periods, with a uni- form gradual transition. It seems to us that this also belongs to the Cheyne-Stokes form of respiration. This phenomenon is by no means rare, particularly if we in- clude the type of cases just de- scribed. It is principally observed in diseases of the brain, in severe disturbances of the circulation, and in toxical states. It occurs in meningitis with tumors of the brain, following cerebral hemor- rhages, etc., and in severe weakness of the heart following diseases of that organ, particularly in fatty degeneration (Stokes); then fre- EXAMINATION OF THE RESPIRATORY APPARATUS. 83 quently in uremia, in cases of morphin-poisoning, in acute diffuse peritonitis, and, finally, in acute infectious diseases, particularly in typhoid fever. It is very seldom seen in persons suffering from slight forms of disease. There have been observed, however, traces of this anomaly of breathing during the sleep of healthy persons (Mosso). We have, on the contrary, almost always to do with patients severely ill, often with stupefied or unconscious ones. Sometimes patients breathe in this way only during an otherwise normal sleep, and then the symptom seems to have proportionally less signif- icance. Cheyne-Stokes respiration is frequently the precursor of the irregular, agonal respiration, and hence, from a diagnostic standpoint, it presages a bad turn. But still, that is by no means always the case, for, in the first place, it is sometimes observed for weeks and even months, especially during the sleep of persons suffering from heart and kidney disease. It also not seldom accompanies transitory toxical states, most frequently, in my experience, in uremia. The manner in which, and the circumstances under which, Cheyne-Stokes respiration occurs points to the supposition that its cause is in an alteration in the function of the respiratory center. Traube and others after him have attempted to find an explanation of the phenomenon. All these explanations result in the supposition of an alteration or diminution of the excitability of the respiratory center in the medulla oblongata, or in the supposition that the excitability of the oblongata becomes ex- hausted. But, in my opinion, no one has satisfactorily explained the peculiar periodicity of the respiration. When there certainly exists a diminution of excitability, and also a liability of the ganglia of the oblongata to become exhausted, as occurs shortly before death from any cause whatever, we simply observe that the respirations become less frequent and more superficial. But no one has yet succeeded in explaining the pauses, and particularly the successive increase of the depth of breathing, in the beginning of respiration after the pauses. Biot's Respiration.—By this designation is understood periodic. pauses in respiration, alternating with normal respirations more or less regular. The phenomenon, which is very rare, occurs most fre- quently in diseases of the brain, particularly in meningitis. The signif- icance of the symptom is the same as that of Cheyne-Stokes' respira- tion. Beyond this one may doubt whether this is not a sub-species of Cheyne-Stokes respiration, or whether it is a phenomenon which is different in principle from it. (c) Difficult Breathing, Dyspnea.—We have to designate that form of dyspnea as physiological which results when the respiratory center is supplied with blood which contains less than the normal quantity of O or an increased amount of C02. In the clinic it is dif- ficult to give an absolute definition, because the perceptions of objective and subjective dyspnea (that is, which are only present in the sensa- tions of the patient), as well as the dyspnea with and without deficiency of oxygen or of blood overladen with carbonic acid, are much mixed. Generally the clinician speaks of objective dyspnea in the following cases : if the respiration is labored, whether the number of respirations be normal, or prolonged, or more frequent. Finally, in all cases ol 84 SPECIAL DIAGNOSIS. increased respiration, if rapid and labored breathing are combined, dyspnea is caused by all those conditions that interfere in any way with the exchange of gases in the lungs.1 But there is another condition which manifests itself by an increased formation and giving off of C02; that condition is fever. Labored respiration with normal or diminished frequency takes place in stenosis of the upper air-passage—that is, of the larynx and trachea. Intratracheal tumors, foreign bodies, inflammations (espe- cially croup), cicatricial strictures (generally syphilitic), granulations, also compression from without, and lastly paralyses of certain laryngeal muscles2 which produce narrowing of the air-passage. The slow and labored respiration in these cases seems a perfectly intelligible means of satisfying the requirements for oxygen, notwithstanding the fact that it is more difficult for air to enter. Strictly speaking, this form of dyspnea often occurs in diseases of the brain.3 At the acme of respiration in Cheyne-Stokes breathing we must speak, too, of there being dyspnea. Increased Frequency of Respiration Occurs— {a) In fever. Here it is often simply increased frequency, the breaths being deeper, but sometimes also we notice that they become somewhat labored (without its being a question of complication of the thoracic organs). The amount of quickening of the respiration varies very much according to the nature of the disease and with the indi- vidual. Nervous persons often breathe remarkably rapidly in fever; with children respirations as high as sixty or more to the minute have often been observed. Nevertheless, in fever every case of marked increase in frequency of breathing must lead to an especially careful examination of the thoracic organs. The cause of fever-dyspnea is, moreover, not alone the increased formation of C02, but is also the result of the irritation of the respiratory center by the warmer blood, as has been proved upon animals by an artificial increase of the tem- perature of the body. Finally, as a third cause of fever a direct effect .of toxins upon the respiratory center is not excluded. Fever-dyspnea may be increased by association with that caused by diseases of the respiratory apparatus. {b) In all conditions that are connected with pain in breathing. Here belong all diseases of the pleura or of the lungs in connection with the pleura (especially croupous pneumonia), inflammatory affections of the diaphragm (trichinosis), of the peritoneum (especially the diaphrag- matic peritoneum), fracture of ribs, and severe rheumatism of the mus- cles of the thorax. Rightly to explain this form of dyspnea is often of the greatest therapeutic value; it may sometimes (not always) be relieved by a narcotic. {c) In diseases of the bronchial tubes which narrow or close the tubes by the secretion or exudation. Here belong all forms of bron- chitis and also bronchial asthma. In the latter disease there is much less swelling and exudation than from bronchial spasm of neurotic origin, which chiefly causes the dyspnea. No doubt spasm of the 1 See under Cyanosis. 2 See under Inspiratory Dyspnea. 3 Also see page 81. EXAMINATION OF THE RESPIRATORY APPARATUS. §5 diaphragm is associated with this sometimes, which causes a prolonged inspiratory expansion of the lungs, and of course this increases the dyspnea. Where there are bronchial asthma and croupous bronchitis in addi- tion to laryngeal croup, there is generally very severe dyspnea with quicker and very forced respiration. Simple catarrh of the bronchial tubes generally leads to quickening of the respiration without the breaths being deeper; for a complete closure of the bronchial tubes cuts off a large section of lung, and so breathing is entirely lost in this section, as in capillary bronchitis, especially in children. The consid- eration of this condition properly belongs to the next section, in that it results in the lung-tissue itself becoming diseased. {d) In all conditions in which the breathing surface of the lungs is diminished or the volumetric variation of the lungs, which is necessary for respiration, is disturbed. These are— All diseases of the lungs: the different forms of pneumonia, edema of the lungs, infarction, tuberculosis, emphysema (this not only on account of the diminished breathing surface, but also the loss of elasticity, and hence diminished contraction of the lungs during expira- tion); the different forms of pleurisy with exudation, pneumothorax; tumors in the chest-cavity which diminish its capacity; abdominal affec- tions which push up the diaphragm;x marked kyphoscoliosis, with the resulting deformity of the chest and consequent unfavorable condition for breathing; paralysis of the muscles of respiration ; and also tonic a?id clonic spasm of the muscles of the chest, as in tetanus and epilepsy, which may occasion the most severe dyspnea. As is evident, these diseases differ widely from one another. Those that diminish the chest-cavity, if they are inconsiderable, sometimes merely restrict the inspiratory expansion of the chest, and so affect the lungs; but if they are marked, then they directly compress the lungs and hence diminish their breathing-surface. It has been already stated that in a number of these conditions the need of oxygen may be met by a substitution of diaphragmatic breath- ing in place of the diminished costal breathing, and vice versa. It is, of course, very calamitous when there is a combination of several causes of dyspnea, as, for example, when a subject of kyphoscoliosis has an abdominal affection which presses up the diaphragm or has inflammation of the lungs. Accommodation, adaptation, plays an important part in many chronic diseases which occasion dyspnea. This becomes most strik- ingly evident if we compare the terrible dyspnea of beginning pneumo- thorax with the relatively comfortable condition of patients who have continually at their disposal for breathing only one lung or even only a part of a lung. In many of these cases it is easy to understand this accommodation—chronic cases, especially phthisical patients, who here come prominently into view, are generally anemic, and therefore require, at least when quiet, only a very small interchange of gases in the lungs; but, nevertheless, every effort at muscular exertion imme- diately causes dyspnea. On the other hand, "lung-dyspnea" is gen- erally considerably increased by the fever which accompanies an acute 1 See above. 86 SPECIAL DIAGNOSIS. disease. Likewise, there are cases where we cannot dispense with the idea, which formerly was not clear, of an " accommodation." Dyspnea further occurs— {e) In diseases of the heart which cause stasis of blood in the lung- circulation. These are insufficiency or stenosis of the left auriculo- ventricular opening; also heart-failure, which may occur in all diseases of the heart. Here the dyspnea is partly explained by the defective aeration of the blood in consequence of the slower circulation in the pulmonary capillaries. But that is not the chief factor, particularly in compensated mitral defects. The question here is regarding another element, which seems to have been made clear by von Basch. In consequence of the overfilling of the pulmonary vessels with blood the lungs are enlarged in volume, and they also contain more air, but at the expense of their elasticity. They become rigid—that is, they are capable of only slight alterations in their volume, similar to emphysematous lungs, but from an entirely different reason.. This swelling and rigidity of the lungs, according to von Basch, gives the first satisfactory explanation of the peculiar dyspnea of compensated mitral defects. Increased and forced respiration. Forced respiration may at any time be associated with rapid breathing by increase of dyspnea. The only exceptions to this are those cases that arise from pain and paraly- sis, both from reasons that are easily intelligible. Mechanism of forced respiration. This is, in the most characteristic way, different from normal breathing—namely, that while the muscles of ordinary inspiration and the mechanical conditions of expiration no longer suffice, inspiration and expiration are assisted by the action of the auxiliary muscles of respiration. The auxiliary muscles of inspiration are—the scaleni muscles in the male (in the female they act even in quiet breathing) as elevators of the first two ribs ; the sterno-mastoidei draw up the sternum when the head is fixed; the pectoralis major and minor, the levatores costarum, the serratus post, super., all of which act as elevators of the ribs, the first named when the upper arms are fixed. In more severe dyspnea the trapezius, the levator scapulae, the rhomboideus are brought into action to elevate the scapula; in severest dyspnea the extensors of the neck assist also, and then we notice the extension of the alae nasi;1 when the mouth is open the soft palate is seen to be drawn up during inspiration; and, finally, even those muscles that dilate the mouth and depress the larynx may be brought into action. The muscles have very varying degrees of importance, the greatest being the work of lifting up the ribs, the sternum, and the shoulders. The expansion of the alae nasi as a symptom is not unimportant, but really does not at all assist in breathing. In expiration the following muscles act in assisting respiration : Of first importance are the broad muscles of the abdomen, especially the transversalis, which compress the abdominal contents, thus pressing up the diaphragm; further, the quadratus lumborum and serratus post. infer., which draw down the lower ribs. It is easy to distinguish at a glance the moderate drawing-in of the 1 See under Nose. EXAMINATION OF THE RESPIRATORY APPARATUS. 87 thorax and epigastrium which occurs in normal passive expiration from the active expiration of dyspnea, by the energy of the act in conse- quence of muscular contraction. Moreover, the contraction of the broad muscles of the abdomen is plainly to be seen. Patients with forced respiration exhibit still other appearances which partly stand in direct relation to the increased energy of the breathing. That the thorax may be entirely easy and that the auxiliary mus- cles may be able to act better, patients prefer the upright posture to lying down.1 Indeed, in very severe dyspnea they may not be able to lie down at all; the arms are steadied, in order that the upper arms and shoulders may furnish a fixed point for the auxiliary muscles; and in order that the sterno-cleido-mastoidei may act most efficiently in assisting respiration the neck is stretched and the face somewhat elevated. Not infrequently the breathing is audible; in forced respiration it is panting, groaning. In stenosis of the larynx or trachea we hear the before-mentioned hissing—stridor laryngeus vel trachealis. The voice is weak, often suppressed; the patient speaks with short, unnatural pauses—interrupted or broken speech. Here belongs the so-called inspiratory " drawing-in." Even in healthy people we sometimes notice with forced respiration that the lower intercostal spaces in the beginning of inspiration sink in some- what, instead of, as in healthy persons, a simple flattening-out from the contraction of the intercostal muscles. Drawing-in that is more marked and is prolonged during the whole of inspiration under all circumstances is pathological; with the very yielding thorax of chil- dren even the ribs and the lower part of the sternum may share in the condition. It shows that the lungs do not follow the motion of the thorax—that, therefore, the air is prevented from entering the alveoli. Hence, all forms of stenosis of the larynx, of the trachea, and like- wise the rare stenoses of the two primary bronchi, cause inspiratory drawing-in on both sides, most markedly of the lower part of the sternum, the lower ribs, and intercostal spaces; if the stenosis is very marked, the condition is extended to the upper ribs and intercostal spaces as far as the jugular and supraclavicular spaces. But stenosis of only oiie bronchus causes inspiratory drawing-in of one side when the breathing has a certain degree of force, besides "lagging" of the affected side. Bronchitis of the smaller tubes, especially in children, may occasion inspiratory drawing-in in a more circumscribed way, as only the lower part upon one side. But we may also sometimes see an extended, very marked drawing-in with extensive capillary bron- chitis (with atelectasis, broncho-pneumonia) in children. As regards frequency, laryngeal croup and capillary bronchitis m children take first place among the causes of inspiratory drawing-in. There are two reasons why stenosis of the upper air-passage causes the drawing-in to be greatest at the lower part of the chest, and which may also affect the ribs of this part: first, the air entering the lungs reaches the lowest part, as being the farthest removed, last; secondly, if the thorax is yielding, it is drawn in by the contraction of the dia- phragm, for if the diaphragm cannot descend when it contracts, since 1 See Orthopnea, p. 29. 88 SPECIAL DIAGNOSIS. the lung does not follow it, then the dome of the diaphragm becomes a fixed point, and the thorax in the neighborhood of the insertion of the diaphragm is drawn inward and upward. Moreover, the lateral region of the thorax above the insertion of the diaphragm sinks in so much because the thorax is softest, and also because there is frequently here the greatest difference between the external and internal pressure. Also, expiratory bulging sometimes takes place in the supraclavic- ular depression,1 especially in marked emphysema of the upper part of the lung, as, for example, after whooping-cough; or in the upper intercostal spaces when large cavities are adherent to the chest-wall, as in pulmonary phthisis. With this condition there is a strongly- marked pressure in the thorax; hence it is observed only in very forced expiration, and especially in strained coughing. Very frequently we find in cases of lung-cavities with expiratory bulging—especially frequent in the second intercostal space—the affected intercostal muscles very much shrunken, sometimes fatty degeneration of them. Finally, the picture of such an unfortunate will be completed by the expression of subjective anxiety, sometimes of the most fearful agony ; by the peculiar expression of the eyes, which is caused by the dilatation of the pupils which usually accompanies dyspnea, with occa- sional protrusion of the eyeballs ;2 by the cyanosis and frequent cold sweat3 According as inspiration or expiration, or both, are difficult, or the auxiliary muscles of respiration are brought into action, we distinguish an inspiratory (pure or preponderating), an expiratory (pure or pre- ponderating), a mixed dyspnea. Purely inspiratory dyspnea exists with paralysis of the posterior crico-arytenoid muscles (dilators of the glottis): here expiration is free, since the escaping current of air presses the vocal bands apart; on the other hand, the in-rushing air brings them in contact like valves, and hence inspiration may be hindered even to threatened suffoca- tion. Tumors and foreign bodies may, moreover, be sometimes so located as, by valve-like closure, almost completely to preclude inspi- ration. Further, inspiratory dyspnea occurs with increased activity of other muscles when certain respiratory muscles are paralyzed4 (as, for example, in paralysis of the diaphragm there is increased thoracic breathing, with co-operation of the auxiliary muscles). Purely expiratory dyspnea is observed with movable tumors situated below the glottis: the outgoing air pushes them against the rima glot- tidis, but in expiration they are drawn to one side. Moreover, a preponderating expiratory dyspnea is peculiar to bron- chial asthma (in addition to the always present inspiratory). Probably we correctly assume that the smallest tubes, spasmodically narrowed are still more compressed by the pressure in the thorax during expi- ration. The disease that most frequently causes expiratory dyspnea is emphysema of the substance of the lungs; the diminished power of expiration is chiefly from the diminished elasticity of the lung-tissue, the contracting force of the lungs; generally there is, besides, dimin- 1 See p. 68. * See Nervous System. 3 q. v. * See p. 85. EXAMINATION OF THE RESPIRATORY APPARATUS. 89 ished thoracic breathing, since, if the thorax be too rigid to expand during inspiration, then it is also not contracted either by virtue of its own elasticity or the traction of the lungs. Bronchial asthma of long duration always causes emphysema of the lungs; then, of course, there is a twofold cause of expiratory dyspnea. In genuine emphysema of the lungs there is always also well-marked inspiratory dyspnea on account of the atrophy of lung-tissue and capillaries of the lung, and hence diminished breathing-surface. More- over, it will be understood that whenever there is expiratory dyspnea, if the difficulty of expiration is not equalized by forced or prolonged expiration, there must result a simultaneous inspiratory dyspnea; there is a diminished interchange of gases in the lungs resulting from the incompleteness of the act of expiration; there is a demand for oxygen, and hence forced inspiration. There is no expiratory dyspnea with vicarious emphysema of the lungs. Mixed dyspnea—that is where it is manifest in equal degree in inspiration and expiration—is by far the most frequent. It accom- panies all the diseases of the respiratory organs not mentioned here; also diseases of the heart, and fever. Palpation of the Thorax. This method of examination has, on the one hand, an independent value, and on the other it confirms, and with sufficient practice even adds to, the results of inspection. It is, therefore, very wrong to omit it. It is indispensable on account of its simplicity, and because, like inspection, it quickly furnishes a result in a general way; moreover, its result is often decisive in differential diagnosis, in a certain direction, relative to vocal fremitus. Palpation of the thorax with reference to the respiratory organs is made for the purpose of ascertaining— 1. Possible pain upon pressure. 2. The respiratory movements of the thorax, especially as to symmetry. 3. Any friction-sounds or rales that may be felt. 4. Vocal fremitus. In addition, there are some rare conditions that are not unimpor- tant in differential diagnosis. The examination with reference to the first and second points may be combined with inspection ; the trial of the third point may suitably be settled during auscultation, either before or after. Ordinarily, we test the vocal fremitus after the completion of percussion and auscul- tation ; hence we conclude the physical examination of the thoracic organs by noticing the vocal fremitus. We pause here in the course of the examination, and only speak of the first and second points; the two others will be introduced under the heads of Percussion and Auscultation. 1. Pain caused by Pressure upon the Thorax.—In diseases of the chest pain is common, accompanying the diseases or elicited by pressure. In case it really refers to an internal organ, and not to the 9o SPECIAL DIAGNOSIS. chest-wall, it indicates disease of the pleura or complication with the pleura. By carefully feeling the intercostal spaces with the tips of the fingers the region that is tender on pressure may be very exactly defined; it is generally less extensive than the territory of spontaneous pain, since the latter ordinarily " radiates." This tenderness sometimes exists with exudative pleuritis, but in this disease it is often wanting ; more frequently it is seen in croupous pneumonia which also involves the pleura, and also in phthisis. In the latter disease it generally depends upon callous thickening of the pleura. It is very important, but also frequently difficult, to distinguish between pleuritic pains produced by pressure from those arising in the soft parts of the chest-wall or the ribs. Phlegmonous inflammations and abscesses of the chest are, of course, easily recognized. Pain pro- ceeding from a rib is generally characteristic: quite circumscribed, it occurs only when pressure is made upon the affected rib (caries, perios- titis, over fractured ribs, slight pressure); also, rheumatism of the chest-muscles occasions no great difficulty, at least when it is in the superficial muscles: the muscle is ordinarily sensitive if pressed between two fingers. On the other hand, it is often not easy to dis- tinguish between pleuritic pain and intercostal neuralgia ; the latter can sometimes be distinguished by Valleix's points of tenderness, which stand wholly out of relation to deep breathing or cough.1 It is impor- tant to remember that neuralgic intercostal pain may be present in affections of the pleura, as in tubercular thickening of the pleura in the lower part of the thorax. In short, we ought, in the absence of other indications which point to a disease of the internal thoracic organs, to refer a pain produced by pressure upon the thorax rather to something else than to the pleura; only continuous pain, always at the same places, over the upper sec- tions of the lungs, arising either spontaneously or from pressure, is suspicious ; this may indicate irritation of the pleura from tuberculosis of the apices. Fractures of the ribs are recognized by crepitation and by disloca- tion of the fragments; also often by the fact that pressure at any part of the broken rib causes pain at the seat of fracture. Moreover, fracture of the rib may cause pleurisy. Caries of the rib may also excite pleurisy. Then in recognized pleurisy caries may be proved to be the cause by the circumscribed pain elicited by pressure upon the rib. It must also be mentioned that if a purulent pleuritis breaks outward {empyema necessitatis) it causes peripleural inflammation, and with this there is pain upon the slightest pressure, besides swelling, redness heat, edema of the skin, and, lastly, fluctuation. To the above-mentioned conditions revealed by palpation of the thorax must be added pulsations of the heart felt through a portion of infiltrated lung lying over the heart, and also in the so-called empyema pulsans (empyema pulsatile). This occurs when there is an accumula- tion of pus lying over the heart, almost always upon the left side to which the pulsation of the heart is communicated. In some cases it is 1 See Nervous System. EXAMINATION OF THE RESPIRATORY APPARATUS. 91 very difficult to distinguish it from aneurysm of the aorta. It can only be done by taking a comprehensive view of the case. (We must be on our guard in puncturing or in making an exploratory puncture.) Sometimes pulsations are even found on the left lower posterior portion of the thorax. Usually several causes combine to produce the pulsa- tion : paresis of the intercostal muscles, higher pressure of the exudate, direct contact with the heart, lastly, as indispensably necessary, power- ful action of the heart. 2. Testing the Movement during Respiration.—With special reference to symmetry, with some practice, palpation is a most excel- lent method. It gives more exact results than inspection, and makes the further examination easier, in that it directs the attention immedi- ately to the diseased side or the region of the thorax affected. The respiration is examined by placing the two hands alike upon the two sides of the chest. In order to test the breathing of the upper divisions of the lungs, place the hands flat in front, gradually diverging below, so that the tips of the fingers reach to the lower border of the clavicle. For examining the lower parts spread out the hands with the thumbs extended, so that the thumbs rest upon the angle of the ribs, and the fingers toward the sides of the thorax. Behind, only the respiration of the lower portion of the chest will be tested by laying the flattened hands, with the thumbs extended, upon the surface in such a way that the points of the fingers reach about to the middle axillary lines. For exact examination it is necessary, if possible, for the physician to be directly before or behind his patient; the latter position espe- cially is often difficult when the patient sits in bed; it is best, then, to have the patient slide somewhat down toward the foot of the bed. It must also be remarked that when the patient is lying down there is not infrequently produced a one-sided after-drawing in front and above by an imperceptible inequality in the position of the patient. It is, however, usually best to look out for this symptom in front above when the patient is in an upright position. When palpation is well performed, " lagging" over the apex in beginning phthisis or the " lagging " of the lower part of one side in pneumonia, pleurisy, infarction, etc. is recognized with great exactness. This is of great importance, because, as I have already said, " lagging " may be in many diseases for some time the only symptom. We may also test the contraction of the diaphragm with reference to its symmetry by palpation. We place the hands so that the finger- tips cover the epigastrium ; in this way may be detected the lack of contraction upon one side {pleuritis diaphragmatica, local peritonitis, unilateral paralysis of the phrenic nerve). Failure to contract upon both sides is, of course, seen at once.1 Benczur and Jonas2 have lately tried to use certain differences in the temperature of different parts of the surface of the body for a sys- tematic demarcation of organs which lie against the parietes of the body, especially of the lungs, from parts which do not contain air. By passing the volar or dorsal surface of the fingers over the thorax they have found that the region over the lungs was always warmer, and 1 Compare p. 74. 2 Deutsch. Archiv f. klin. Median, Bd. xlvi. 92 SPECIAL DIAGNOSIS. they assert that by means of thermopalpation it is possible to make out exactly the line of demarcation between the lungs, heart, liver, etc., also from pleuritic exudations, and even to make out their relative dulness. That there are differences of temperature they prove by means of delicate methods of measuring. However, after having made a few experiments ourselves, we are obliged to deny the clinical useful- ness of thermopalpation, because the respective differences are too slight to be indubitably recognized by the finger. PERCUSSION OF THE THORAX. General and Preliminary Remarks regarding Percussion.1 In daily life we learn on every hand that bodies of different physical structure give forth different sounds when struck. We also sometimes strike an object in order to determine from the sound it gives forth what its physical condition is—that is, whether it is hollow or solid. This is the principle upon which percussion is practised on the human body: from the sound elicited by the blow we judge of the physical condition of the part which lies beneath the covering of the body within the sphere of our percussion-stroke. Hence, percussion gives direct information regarding organs or parts of organs which lie approximately near to the surface of the body; in general, by this method we penetrate only to the depth of 5 or, at most, 7 cm. 1. History and Methods.—The honor of the discovery of per- cussion belongs to a physician of Vienna named Auenbrugger; the paper in which he made known his method appeared in 1761 urider the title, Invcntum novum ex percussione thoracis humani ut signo abstrusos interni pectoris morbos detegendi. For almost half a century Auenbrugger's discovery was, on the one hand, declared to be without importance, and, on the other, was ridiculed until the year 1808, when Corvisart, body-physician to Napoleon I., emphatically revived and largely improved it by a translation into French, with a commentary. Then the truth began really to prevail, especially by the influence of Piorry in France and Skoda in Vienna. The former was the founder of topographical percussion. During fifty years the method gradually became common professional property. Further, and up to the most recent time, it experienced improvement and explanation of every kind, especially by Wintrich, Traube, Biermer, Gerhardt, and Weil. For some time past, especially since the labors of Weil, it appears that a degree of certainty has been reached in regard to this proceeding. In the course of the development of percussion several methods of striking the body have been discovered, most of which still have value to-day. Auenbrugger struck directly upon the thorax with the tips of the fingers—direct or immediate percussion. Piorry discovered indirect or mediate percussion in that he placed under the percussing finger a small plate of ivory, a pleximeter. 1 In this chapter the author follows in many ways, but not entirely, the views and methods of presentation of Weil, whose well-known and excellent work has done much to establish this subject upon an accepted basis. EXAMINATION OF THE RESPIRATORY APPARATUS. 93 Wintrich introduced the percussion-hammer, which had already been sometimes used by Laennec and Piorry, in place of striking with the fingers. But finally, in more recent times, the method of indirect percussion, without instruments, has very widely prevailed. The index or middle finger of the left hand is used as the pleximeter, which is placed upon the spot to be percussed, and it is struck with the index or middle finger of the right hand (finger-percussion). Of these methods, that of Auenbrugger, the direct, has been dropped as being less practical, while nowadays the three in use are all examples of the indirect method: I. Finger-percussion. II. Finger-pleximeter percussion. III. Hammer-pleximeter percussion. All three are practised and taught by good teachers of percussion ; all three, in reality, yield equally exact results; the secret of their value lies in their application. The fact of the matter is that one who thoroughly understands finger-percussion can very quickly acquire a knowledge of the two other methods. Hence I am most heartily in accord with those who in their teachings and writings emphatically recommend their students at first to practise the finger method of per- cussion exclusively. I think it superfluous for me here to go into particulars regarding the technique—these can only be made clear in the clinic—but I must remark that the greatest difficulty in finger-percussion is in holding the percussing finger crooked like a hammer, and at the same time having the wrist-joint move quite freely. Also, the numerous forms of percussion-hammers and pleximeters (the latter of glass, ivory, hard rubber, and wood in different forms) cannot be described here. It appears to me that the hammer with a wooden handle and a metal head, not too heavy, is rather to be recommended ; likewise, a medium- sized oblong ivory pleximeter, about 2 cm. wide, and the so-called double pleximeter of Seitz. Even to those who practise finger-percus- sion this last is recommended for percussing the supraclavicular depressions. There have lately been invented small thimble-like Coverings for the percussing finger to be used as a substitute for the hammer. They seem to us to be worthy of notice, though we have not yet had much experience with them. But after various trials we do not think it is practical to provide the finger that is used as a pleximeter with a rubber ring or anything of that sort. There is one point of great importance—that the individual should, as much as possible, be similar and uniform in his methods through- out: in percussing, if the finger method is used, he should always strike upon the index or always upon the middle finger of the left hand; the pleximeter, if that is used, should always be used in exactly the same way, etc. Nothing is worse than frequently to change methods or instruments, be the change ever so slight. But if physicians, as is true of many, are accustomed ordinarily to percuss without an instrument, but at certain parts of the thorax where it is difficult to use finger-percussion they regularly employ a pleximeter 94 SPECIAL DIAGNOSIS. or both pleximeter and hammer, there is no objection to this twofold method; only the examiner must be master of the two methods which he employs. It is well also always to repeat the same method upon the same parts of the body. 2. Qualities of Sounds.—By striking upon the body we cause a sound. This percussion-sound differs according to the condition of the part of the body which is shaken by our percussion-blow. From this fact there results directly two main points, which form the basis of the doctrine of percussion : I. When we strike upon a solid portion of the body entirely free from air we elicit a toneless sound of the least possible intensity and duration; it is designated as " absolutely deadened " or as a " thigh sound," since it is like that caused by striking upon the thigh. [Dead- ness: I have frequently used this word and its derivations as giving a useful and accurate discrimination from the familiar English terms flat- ness, dulness. Deadness is more than dulness.—Translator^ II. If organs containing air lie in the range of our percussion-blow, then these give forth a sound of a certain intensity, duration, and tone; this sound is designated as " clear." The clear sound of organs containing air may have only a different degree of intensity or clearness. Its intensity depends upon— i. The length of the oscillation. It is therefore stronger the stronger the blow, and, moreover, the nearer the organ containing the air is to the percussing finger—that is to say, the less the percussion- stroke is weakened by the tissue, as fat, muscles, bones [also clothing], intervening between it and the air-cavity. 2. By the volume of the parts of the air-containing tissue set in motion. Hence, with equal strength of percussion we have in different parts of the body different intensity and different clearness of sound accord- ing to the greater or less amount of air which the tissues contain, or according to the nearness or distance of the air-cavity from the surface of the body—that is, from the percussing finger. It is according to the change of these conditions in the human body that we obtain the different clear sounds: we may meet every grade from absolute deadness to a very clear—the peculiarly clear—sound. These intervening grades are designated as " relative dulness " (that is, in comparison with a real clear sound it is dull). Absolutely dead or dull sounds differ according as they proceed from muscle, bone, etc. We cannot wholly ignore these differences as if not existing. On the other hand, the clear sounds fall into the two following important divisions: i. Tympanitic sound (the name is from tympanon ; the kettle-drum or tymbal, not exactly, but very nearly, produces it). This approaches a musical note, so that we can exactly define its place on the musical scale, and it is actually shown formed from regular oscillations in the rotating reflected image of the sensitive gas-flame. It possesses also according to the different conditions to be described later, sharply definable differences of pitch. A tympanitic sound, such as is fre- quently met with in the body, can easily be produced if one strikes EXAMINATION OF THE RESPIRATORY APPARATUS. 95 upon his own cheeks which have been inflated, but not too strongly stretched. b' 2. The clear sound called non-tympanitic, also more briefly " lun«-- sound "—a very practical designation. This has no sound definable by its pitch, but yet it may be known in general as " high " or " deep." Hence, both the tympanitic and the non-tympanitic sounds have a certain intensity and duration; but while the latter may be only approximatively designated as high or deep, the pitch of the tone brings it toward the tympanitic. Both occur in a very high degree of clearness and in all degrees of relative dulness (" relative dulness " or " dull tympanitic sound "), even to an often unnoticeable transition to absolute dulness. i. We give here and later on some schematic drawings which are designed to facilitate the understanding of the foregoing points. We can recommend the application of this manner of representation to teachers of percussion, as well as to the student for his private studies or for his notes of what he has seen and heard in the clinical courses. Percussion of the lungs is represented in a rough schematic draw- ing in which a long arrow signifies strong percussion, a short one weak percussion. In the first and third drawings the parietes, for the sake of simplicity, are represented as being of uniform thickness. The hatched triangles in each figure represents the portion of the lung Fig. 25. Fig. 26. Fig. 27. Fig. 25.—Schematic representation of the difference between strong and weak percussion, the conditions being otherwise the same. The length of the arrow indicates the strength of the percussion, the size of the hatched triangle, the extent of lung-tissue affected by the percus- sion-blow, and also the intensity of the sound. Fig. 26.—Represents the different results, with equal percussion force, where the thick- ness of covering varies : clear sound ; relative dulness ; no sound—that is, absolute deadened sound. Fig. 27.—Represents the influence of the volumes of resonant body upon percussion: over the apex and border, on account of the small volume of lung: with equal and moderately strong percussion and equal thickness of covering, the sound is less intense than over other parts of the lung. which is set in vibration by the percussion-blow, and also the intensity of the sound. Figs. 25, 26, 27 show how the intensity of the sound is influenced {a) by percussion with different degrees of force, \b) by different thicknesses of the parietes, and {c) by the depth or volume of air contained in the organ. 96 SPECIAL DIAGNOSIS. 2. In the foregoing we give those designations which in late years we have without exception employed in our instruction on percussion. Regarding the large number of other terms for qualities of sound which the older teachers of percussion have introduced, but which, to the great advantage of clearness of mutual understanding, have more and more disappeared from the literature of the subject, we refer to the classical work by Weil on Topographical Percussion. We have in fact, as will be seen, followed the nomenclature proposed by Weil, with only one exception ; the term dull sound is avoided, and in place of it we have employed the expression (which, it is true, is somewhat cir- cumstantial) "absolutely deadened sound," or "thigh-sound." This was done because, over and over, we found that pupils were reminded of the " dull sound of the kettle-drum," " dull roaring," etc., and hence were confused—in short, because the expression does not grammati- cally designate what is intended in teaching percussion. " Absolute deadened sound " is an expression which has this advantage—that to the beginner it is a new association of words; it cannot, therefore, so easily occasion confusion. Moreover, the expression always summons one to a more exact testing as to whether, at the particular place, there is really absolute or only relative dulness, and also it seems to us pref- erable, for every teacher of percussion knows how much this is needed —that, for instance, in percussing the lower part of the right mammil- lary line the so-called relative liver-dulness is spoken of as absolute deadness. 3. For the sake of brevity and clearness we also have really not gone into the many ideas and the manner of explaining them presented by others on this subject, which was formerly quite confused, and is even yet difficult to master. But we cannot abstain from citing here, by reason of their historical interest, the three fundamental sentences from Skoda: {a) All fleshy parts not containing air (except tense membranes and filaments), also fluid accumulations, give an entirely dead and empty, scarcely distinguishable percussion-sound, which can be demonstrated by striking upon the thigh. {b) Only bones and cartilage when directly struck give a peculiar sound. {c) Every sound which we elicit by percussing the thorax and abdo- men, and which differs from the sound of the thigh or bone comes from air or gas in the chest or abdominal cavity. 4. The acoustic character of the clear and that of the relative or absolutely dull sound is clearest expressed if we say: the dull sound is a very slight noise of short duration ; the clear, non-tympanitic sound is a noise louder and of longer duration, with a trace of being a note • this latter, however, is so little apparent that it either cannot at all be recognized, or only in general, as to its being high or deep. In the tympanitic sound, with the discordant mingling of tones, there pre- dominates a tone of such a character that it is plainly heard and its musical pitch distinguished. 3. The Conditions that Determine the Quality of the Sounds and their Production in the Body.—The Feeling of Resistance.—The tympanitic sound exists— EXAM1NA TION OF THE RESPIRA TOR Y APPARA TUS. 97 I. Over cavities that contain air or gas if they are surrounded by walls moderately smooth and capable of reflexion, and if they com- municate with the external air through an opening; the walls may be stiff or yielding. The intensity of the tympanitic sound thus produced depends upon the conditions (mentioned on page 94) influencing the intensity of clear sounds in general. The musical pitch of the sound is determined by— {a) The size of the communicating opening: the larger it is, the higher the tone; {b) The volume of the cavity containing the air : the larger the cavity, the deeper the tone; {c) If the walls are yielding, membranous, by their tension: lax membranous walls make the tone deeper. 2. Over air-containing cavities with yielding, membranous walls if the cavities are closed—that is, do not communicate with the external air ; only the walls, and with them the enclosed air, must not be too tense. Here the pitch is determined only— {a) By the volume of the air-cavity: see above under 1. {b). {b) By the degree of tension of the wall; see above under 1. {c). But if the tension of the wall (and with it the enclosed air) of a closed cavity reaches a certain degree, then the percussion-tone becomes clear and non-tympanitic. Likewise, cavities that are closed on all sides by stiff walls give a non-tympanitic sound. The tympanitic sound mentioned under 1 is called "open," that under 2 " closed." The former has a much more pronounced tympanitic character—that is, the pitch of the tone appears more distinctly—than the latter. When the cavities are cylindrical, communicating outward by an opening, the pitch of the tone is determined by the length of the cylinder: the longer it is, the higher the tone. Some experiments, illustrating what has been said, are easily performed and are strongly recommended to beginners : Take an empty Florence flask and percuss upon its mouth, either directly or hold the pleximeter lightly over its mouth; then diminish the quantity of air by partly filling the bottle with water; if possible, also compare the differences of pitch which are produced by different lengths of the neck of the bottle, other condi- tions remaining the same. Percuss a rubber gas-bag which is at first only moderately inflated, then more tensely, with air. In this way one can very easily illustrate the most important of the laws that have been mentioned. 3. Finally, tympanitic sound occurs under quite other conditions— namely, in certain conditions of the lungs which have this in common, that they probably accompany a want of tension of the lung-tissue. Referring to what was said above under 1, we add that the open tympanitic sound occurs in the human body, under normal relations, when the mouth, larynx, and trachea are percussed; pathologically, when percussing lung-cavities which are in open communication with the air-passages; further, if, in consequence of shrinking of the apices of the lungs, the trachea, or in consequence of shrinking or thickening of the lung where it covers a fissure, a primary bronchus would be reached by the percussion-stroke, and would, therefore, be itself per- 7 9S SPECIAL DIAGNOSIS. cussed; and, finally, the open tympanitic sound sometimes occurs with open pneumothorax. Herewith we notice a peculiarity of this sound which truly stands in a certain (although still not altogether clear) relation to the laws above enunciated regarding the pitch of the open tympanitic sound: the sound is higher with the mouth open, deeper with the mouth closed. If this occurs when percussing a lung-cavity (or also in open pneumothorax), it is called Wintrich's change of sound; if on percus- sion of the trachea or a primary bronchus, then we speak of Williams's tracheal tone} In addition to what was said above under 2, we remark that in the human body the closed tympanitic sound is heard over the stomach and bowels; in rare cases over closed pneumothorax; and, finally, in pneumopericardium. Now, while it is difficult to apply the rules regarding the change of pitch to the open tympanitic sound, since the cavities of which we are speaking are of extremely complicated form and have very dif- ferent walls, the influence on the one side of the volume of the cavity, and on the other of the tension of a membranous wall, is shown over the stomach and intestines. A greater volume, as in the stomach and colon in comparison with that of the small intestine, deepens the sound, while increased tension heightens it, and even renders it non-tym- panitic. We add to what was said above under 3 that the normally clear, non-tympanitic sound over the lung becomes tympanitic if the tension of the lung-tissue diminishes—i. c. if the lung, following the pull of its elasticity, is able to retract. This is true in all cases where the pleural cavity is diminished, hence especially in exudative pleuritis. The tym- panitic sound is found where the retracted lung lies against the thorax. All the other changes of the thoracic and abdominal cavities which have been mentioned before2 as working in the same way, occasion these phenomena. Probably, for the same reason—i. e. in consequence of the relaxa- tion of the lung-tissue—a tympanitic sound is heard in croupous pneu- monia during the stages of engorgement and of resolution ; in edema of the lungs ; and finally in the neighborhood of thickened parts of the lungs. In the latter relation the tympanitic sound over the apices of the lungs in the beginning of tuberculosis, where lung-tissue containing air is situated between groups of small tubercular masses, is of some diagnostic importance. In these cases we must assume that the lung-tissue has become loose and ductile, and has therefore lost its power of stretching. It has not yet been established that this explanation is correct. Metallic Sound.—We thus designate such a variety of tympanitic sound by which a metallic character, produced by a very high over- tone, either occurring with the sound itself, a peculiar metallic tone or it is produced afterward, metallic after-sounds. The metallic sound exists over not too small, very smooth-walled, regular cavities both open and closed. Hence, we find it sometimes over the normal stom- ach, intestines, and sometimes over lung-cavities, in pneumothorax, pneu- 1 See, regarding this, pp. 106, 113. 2 See p g5 EXAMINATION OF THE RESPIRATORY APPARATUS. 99 mopericardium. It is best brought out in percussion with the so-called rod pleximeter or in percussion-auscultation (Heubner).1 The clear non-tympanitic sound occurs where, " within the sphere of action of acoustics, there is found tissue containing air, but whose capacity for vibration is more diminished than in those cases in which the tympanitic sound occurs." 2 It is heard over the normal lungs—a remarkable fact, since a lung that has been removed from the body, even if it is inflated to a volume corresponding with the condition during life, gives a sound that more nearly approaches the tympanitic than the non-tympanitic. Why a lung in the thorax loses wholly the tympanitic character of its sound is not entirely clear, but we cannot help thinking that, in some way or other, the chest-wall is the cause. The intensity of this lung-sound is sufficiently explained by the rules given above; its pitch, only approximately recognizable, is chiefly influenced by the tension of the lung-tissue. We have mentioned above that retracted and relaxed lung-tissue gives a tympanitic sound; if the tension is only slightly diminished, then there is only a very deep {and abnormally clear) non-tympanitic sound. This, occurs, also, in emphysema of the lungs, but sometimes in exudative pleurisy, and also in pneumonia in the air-containing, compressed, infiltrated adjacent sec- tions of the lungs. The transition from the non-tympanitic to the tym- panitic sound over the lungs may be thus summarized: According to the diminution of the normal tension of the healthy lungs, there takes place in the thorax a change of the clear non-tympanitic sound to an abnormally clear and deep, and in very marked relaxation to a tym- panitic, sound. To the above corresponds the fact that in very deep respiration, at the height of inspiration, at many points of the thorax, the respiratory sound is distinctly higher, while in deep expiration it is deeper (" change of respiratory sound "—Friedreich). Moreover, we hear the lung-sound over the stomach and bowels if they are very much inflated with gas, where gas, as well as wall, is under marked tension ; finally, when the walls of the cavities of the body are made tense by the entrance of air into them. This espe- cially happens in most cases of pneumothorax (except that open pneu- mothorax frequently gives a tympanitic sound).3 The deadened sound. Absolutely deadened or thigh-sound is met with " if only structures that are free from air he within the sphere where the percussion-stroke acts acoustically" (Weil). Since this, at best—/ e with the strongest percussion—reaches only to the depth ot 6 to 7 cm., and not so much as this in a lateral direction, therefore m case of only strong percussion absolutely deadened sound after all would be found where we percussed over airless structure of sufficient size if an organ containing air were not directly m contact with it. If we percuss still less strongly, we should, as a matter of course, the sooner receive an absolutely deadened sound. In the human body we have next to consider the internal organs not containing air, called " parietal" if they lie in contact with the wall of the body; and also the coverings (subcutaneous fat, muscles, bones) i See later. 2 Weil: Handbook of Topographical Percussion, 2d ed., p. 35. 3 See above. 100 SPECIAL DIAGNOSIS. if they are of sufficient magnitude. Thus, frequently, in the region where the heart is parietal, and, further, where the liver also is, even with strong percussion there is absolutely deadened sound. Not infrequently, however, especially over the heart, absolute deadening does not exist, since the structures containing air lying under or near by may be reached chiefly through transmission by the chest-wall, Entirely deadened : Clear: Covering of the body: Fig. 28.—Diagrammatic representation of percussion over a thick covering of the body. The short arrow indicates weak, the long one strong, percussion. With weak percussion we have absolutely deadened resonance; with strong percussion a clear, although less intense, sound (indicated by the hatched triangle). though it may be only by its vibration, and may give the clear sound belonging to the air-containing structures. As regards the skeletal coverings, in abnormally fat persons and in edematous diseases, these sometimes attain such proportions that even strong percussion yields an absolutely deadened sound; in normal, moderately fat persons it is only the fossa infraspinata that very fre- quently gives an absolutely dull sound. But, further, parietal tumors, and especially fluid accumulations in the pleura and peritoneum (more rarely thickening of the lungs), occa- sion absolutely deadened sound in case they, together with the skeletal covering, possess sufficient depth and breadth. Moreover, over ribs markedly bowed, as over the point of sharpest bending-out of the thorax in kyphoscoliosis, absolutely deadened sound may take the place of the lung-sound; also here a peculiar change of the lung (aplasia) often plays some part. But under the circum- stances mentioned above there may be relative or even absolute dulness of sound over perfectly normal lung-tissue. Furthermore, it is to be remembered that when the body lies on pillows, etc., these tend to diminish sound in parts immediately in con- tact with them, because the integument and subjacent tissues, particu- larly the ribs, do not vibrate so readily when close against anything, and for the same reason they cannot transmit vibrations. Thus there is dulness in the sloping lateral parts of the thorax if the patient is lying upon his back in bed. This dulness, though insignificant, is yet pronounced enough to obliterate fine differences or to lead to error where a nicer distinction is required. Relatively dull sound occurs where air-containing structures of only small size are percussed, or where structures containing air are made to vibrate only slightly by percussion, or where these two conditions are met with together. Thus, a relatively dull sound is obtained with feeble percussion of air-containing structures, while strong percussion Lung EXAMINATION OF THE RESPIRATORY APPARATUS. IOI of the same yields a clear sound : the blow reaches only a small volume of the air-containing organ, and it moreover causes in it oscillations of only moderate amplitude. Likewise, where the volume of lung-tissue is small, as over the apices and just over the lower border of the lungs, the sound is relatively dull, and this is true even with strongest percus- sion, since there is here only a small portion of air-containing material to be acted upon. Finally, every layer of airless tissue which lies over an air-containing tissue or space causes a deadening of the percussion- sound of the latter—i. e. a relatively deadened sound—if the overlying layer is not so thick as to cause an absolutely deadened sound.1 Sub- cutaneous fat, muscles, bones, parietal tumors, thickening of lungs, layers of fluid, callosities,—all these, as overlying airless masses, deaden the sound in proportion to their size. A special description is required both of parietal and of deeply- Clear :.—»■■/»» No difference in Relatively dull:—*L clearness: J Lung Lung Weak percussion. Strong percussion. Fig. 29.—Diagrammatic representation of the value of gentle percussion in determining parietal condensation in the lungs. The length of the arrow indicates the strength of the percussion, the size of the hatched triangle the extent of the vibrations in breadth and depth. We notice that weak percussion is better, because it gives a deadened sound over the thickening, while over the lung it gives a clear sound. seated airless parts which normally contain air, such as occur espe- cially in the lungs as acute and chronic pneumonic thickenings, infarc- dear : Absolutely dull. Less difference in clearness: Lung I WF Strong percussion. Weak percussion. FIG. 30.—Diagrammatic representation of the value of strong percussion in determining condensation in the lungs lying at some distance from the surface. The strength of the percussion-stroke is indicated by the length of the arrows. The hatched triangle shows the extent of the oscillations in breadth and depth. Hon, and tumors. For ascertaining such solidifications, if they are parietal, it is necessary not to percuss too strongly; then we shall 1 See above. 102 SPECIAL DIAGNOSIS. plainly make out the place where there is air by the difference in sound if the given patch of thickening measures as much as about 5 cm. in breadth and 2 cm. in depth (see Fig. 29). Deposits which, on the other hand, are located at about 3 to 4 cm. in depth, if they are corre- spondingly large, may be detected, but only by very strong percus- sion ; then we elicit a relatively deadened sound in the midst of what is quite normal, as is shown by Fig. 30. Sensation of Resistance.—We introduce here the description of this symptom, although it really belongs under Palpation, but in truth it is most intimately connected with Percussion. With the percussing finger (less distinctly with the hammer) the examiner forms an opinion of the degree of resistance, or, to express it better, concerning the degree of capacity of the parts lying beneath it to vibrate. This feeling of resistance is strongest, the power to vibrate least conceivable, where it is absolutely deadened, the sound identical with the " thigh-sound;" hence, normally, where we strike upon thick muscle, also bones and muscles; pathologically, it is especially distinct over large pleuritic exudations, very thick pleura, solid parietal tumors of the chest; over large solid abdominal szvcllings; and in extremely rare cases in extensive thickening of lungs, where the bronchi are completely stopped (as in the so-called " massive pnewnonia" of the French). When the percussing hammer is used to ascertain the feeling of re- sistance the index finger is placed upon the head of the hammer. This has always seemed to me a very poor substitute for finger-per- cussion. Other authors, as Weil, find a marked feeling of resistance only over massive layers of fluid. I have often convinced myself of the presence of marked resistance in the cases above mentioned. 4. Topographical Percussion: Determining the Parietal Boundaries of Organs.—Only of a part of the internal organs can we determine the boundaries by percussion on the surface of the body. The conditions of such determinations are these: {a) That the given organ be parietal. {b) That it yield a sound differing from its surrounding tissues. Hence, we can mark off the boundaries of a parietal organ that gives an absolutely deadened sound from one that gives a clear (tympanitic or non-tympanitic) sound, as the liver from the lung or stomach, the heart from the lung; of a parietal organ that gives a tympanitic sound from one that yields a non-tympanitic sound, as the lung from the stomach or the intestine; of parietal organs with tympanitic sounds of different pitch, as the stomach from the intestines ; and also, though very seldom, two organs of non-tympanitic sound in case they are of very different pitch, as pneumothorax from lung lying against the opposite side. But we can never recognize the boundaries between two organs giving deadened sound (heart and liver), nor between the heart and fluid effusion in the pleura.1 Method of Determining the Boundary.—Generally we percuss from an organ that yields a clear sound toward that which gives a deadened 1 See below. EXAMINATION OF THE RESPIRATORY APPARATUS. 103 sound, and upon the line which stands perpendicular to the expected boundary-line. Hence the pleximeter or the pleximeter finger is placed parallel to where the expected boundary-line lies. We proceed by long stages upon this perpendicular (striking it at intervals of about 3 cm.), until the sound has so distinctly changed that we are convinced that we are over another organ. Then we define the boundaries by placing the pleximeter at shorter and shorter intervals until we have defined the boundaries as sharply as possible. This is traced by means of a blue pencil. After the boundaries have been determined at various points and they have been thus marked, then the points are united in a line, which is the boundary-line of the particular organ. The rule most important to observe is to percuss very lightly along the border of the organ we are trying to locate. It is easy to see the reason for this : I. By strong percussion, as of the liver close to the lower bor- der of the lungs, we should at the same time disturb the adjacent lung, and so would elicit a noticeable clear sound, and we should then easily think that we were still over the lung. In the same way, in determin- ing the lower border of the liver, by strong percussion we disturb the intestine which here lies under the thin portion of the liver, and so get a tympanitic tone. 2. The ear perceives the very slight differences of sound which exist upon the border-line (we remember the lower border of the lung, how the clear sound yielded by it must have slight in- tensity) better if the sound is itself slight. For those who are trained the simplest method may be recom- mended, that on approaching the boundary between the two organs one should successively percuss the more lightly. The dermatograph of Johann Faber for marking the boundaries on the body can be very strongly recommended. In important cases it is advisable to mark upon an outline drawing of the body what has been found by percussion. One can use with great advantage rubber stamps for these outlines. They enable the physician to quickly enter his findings at the appropriate place in each individual history. After this indispensable explanation of the general rules for percus- sion and their practical value, we again take up in succession the methods of examination of the respiratory organs, beginning with the percussion of the thorax. Percussion of the Thorax, especially of the Lungs. I. Methods.—It is best first to percuss patients who are out of bed in the standing posture, and later, if necessary for the front of the chest, lying down. Upon bedridden patients the examination of the chest'is conducted with the patient in the dorsal position ; for percuss- ing the back we have the patient sit up. We must then take care that the patient sits in a symmetrical position, but with the least possible tension of muscles; the head is held exactly straight, and especially in percussing the supraclavicular depressions it must not be turned; in the dorsal position the arms lie quietly by the side of the thorax. Both in sitting and standing the patient bows the back a little, inclines the head slightly forward, allows the shoulders to hang, and folds the 104 SPECIAL DIAGNOSIS. forearms across the chest. Every contracting muscle increases the thickness of the covering by its swelling and increases the impression of dulness; hence, contraction of the muscles of the thorax must as much as possible be prevented. In finger-percussion of the front of the chest with the patient in the dorsal position we approach the bed if possible so as to stand on the left side of the patient. From the other side it is not possible to place the finger of the left hand, used as a pleximeter, symmetrically1 upon the two sides in both supraclavicular spaces. We proceed in such a way as to compare at every situation the percussion-note of points that are symmetrically located. We must take particular care to strike exactly upon symmetrical points, other- wise the " comparative percussion" has no value. Moreover, since we wish to make an exact comparison throughout, we take care also not only to percuss at symmetrical points, but to percuss with equal strength and somewhat moderately. We first percuss the supraclavicular depressions—first on the right, then on the left, whereby, in cases where it is of special importance, we determine the upper boundaries of the apices of the lungs ; then, in the same way, the infraclavicular spaces are percussed. On the two sides in finger-percussion We must, if possible, hold the pleximeter hand in such way as always to have the wrist toward the middle line of the thorax and the pleximeter finger pointing outward. Then we percuss the third intercostal space right and left, then downward only on the right, and usually only in the intercostal spaces. We do not further compare it with the left side, since here lies the heart, which is percussed by itself. Then follows the determination of the right lower border of the lungs according to the rules given above regarding the determination of parietal organs. We percuss upward, comparing the two sides of the thorax, again in the intercostal spaces. When we wish to percuss high in the axillae the arms are to be abducted. Then follows the determination of the boundaries of the right and left borders of the lungs in the middle axillary lines. Some- times it is valuable also to percuss from the infraclavicular spaces side- ward and downward upon a line which is at right angles with the course of the ribs. In percussing the back we first compare the sound over the apices of the lungs, thus completely defining their upper boundaries ; then we percuss on the right and the left, comparing corresponding intercostal spaces as we proceed downward to the lower borders of the lungs. Then we percuss on the sides of the spine below the angles of the scapulae, comparing symmetrical points. The boundaries of the lungs are best determined in the scapular lines. In this way the thorax is generally to be percussed. But the presence of pathological conditions that require one to be especially careful in the examination of certain parts may give the preference to special methods of examination. These have been in part already mentioned in the general division. They follow directly from what was said there. They will be again mentioned in the description of percussion in pathological conditions of the lung. 1 See below. EXAMINATION OF THE RESPIRATORY APPARATUS. 105 2. Normal Sound over the I^ungs, Trachea, and larynx.— The Normal Boundaries of the I^ungs.—It is shown that in per- cussion of the lungs in general over the normal lung there is elicited a non-tympanitic sound. But this sound as regards its intensity is indi- vidually very different in different persons; also, in each single chest it is not alike throughout, but exhibits individual regional differences. The individual variations arrange themselves first according to the amount of fat. Very fat bodies give a less clear thoracic sound, or in order to yield a clear sound they must be percussed more strongly, requiring perhaps the use of the hammer; but it is evident, as we have said, that this is unfavorable for determining the boundaries, for which the rule is to employ very light percussion.1 Further, the percussion-note of the chest differs according to age : with children, having a more elastic thorax, as well as with aged per- sons, with thin structural coverings and somewhat lax or rarefied lungs, it is higher in pitch than in persons in middle life. But also in the individual thorax the different regions normally give different clearness of sound. In other words, one region com- pared with another yields a relatively deadened sound, and according to the two chief points of view previously mentioned—namely, accord- ing to the varying thickness of the covering and according to the size of the lungs. Hence we remark the following facts: {a) Over the apices of the lungs, even with strong percussion, the sound is not very intense; for, though the covering is thin, the volume of lung-tissue is small. {b) In the infraclavicular spaces, and still more in the second inter- costal spaces, the sound is very intense (covering thin; volume of lung- tissue greater). {c) Farther down, not only in the male, but in still higher degree in the female, the sound is deadened by the pectoral muscle or by this and the mamma; in the female the sound may be absolutely deadened over the mamma, and this notwithstanding the fact that the lung-tissue is here very considerable. {d) Upon the back the apices yield a sound of very slight intensity, since here there is a very small volume of lung and a very thick body of muscle Over the scapula there is likewise a very deadened sound— at the spine and directly below even a thigh-sound. In the interscap- ular spaces the sound is clearer. {e) Below the scapulce and at the sides of the chest the sound is very intense. (/) Strictly speaking, here also belongs the description of the so- called "relative heart- and liver-dulness."2 Now, it is further very important to know which similarly situated points on the thorax normally give the same kind of sound, since it is especially by comparative percussion that we seek to ascertain the presence of disease on one side. We may say that in healthy people marked dissimilarity of sound at symmetrical parts of the chest on the right and left sides exists only— In the neighborhood of the heart, as compared with the correspond- ing part on the right. 1 See above. 2 See P- Io8' io6 SPECIAL DIAGNOSIS. At the two sides: on the left side normally the sound, almost as far back as the spine and forward in front at varying height as far some- times as the fourth rib, is often clearer than on the right, and of some- what tympanitic tone (combining with the sound of the stomach or colon). In addition, there is a slight inequality sometimes posteriorly over the apices. In right-handed persons the sound on the right side at that location may sometimes be met with a little less clear, because the muscles from use are somewhat more developed. On the left side, in left-handed persons, the case is reversed. Lastly, it is necessary to mention a point of greater importance—that over the ivhole of the sternum there is a clearer, non-tympanitic sound even where there is no lung-tissue at all, as at the upper part of the manubrium (trachea) and over the left half of the lower part of the corpus sterni. The sternum acts as an unusually thick pleximeter, and yields, therefore, throughout and in equal strength, the sound of the lung lying in contact spread out over its inner surface. The larynx and trachea in the neck in front give the tympanitic sound of a hollow cavity with smooth walls. This has the peculiarity of being higher and more plainly tympanitic with the mouth open than with it closed {Williams's tracheal tone, tracheal change of sound). The cause of this phenomenon is not quite clear; the explanation given by Neukirch and accepted by Weil is based upon the assumption of the resonance of the mouth changing with its opening and closing. This will be referred to later. Normal Percussion-boundaries of the Lungs.1—It is not possible to define the boundaries of the lungs perfectly by percussion. More- over, by percussion we can only establish— I. The apices so far as they rise above the clavicle: they are dis- tinguished by their clear sound in comparison with the deadened sound of their surrounding soft parts. 2. The boundaries of the left lung at the incisura cardiaca: the lung sound from the absolutely deadened sound of the heart—the lung-heart boundary. 3. The lower borders of the lungs, this especially at the lower border of the right lung: the lung sound marks the boundary of the abso- lutely deadened sound of the liver—the lung-liver boundary. At the lower border of the left lung, first about from the mam- millary to the middle of the middle axillary line, the lung sound marks the boundary of the tympanitic sound (stomach, or more rarely also intestines)—lung-stomach boundary; next, the lung sound from the deadened sound of the spleen—lung-spleen boundary ; and, lastly, from the deadened sound of the kidney—the lung-kidney boundary. It is difficult to determine the boundaries of the lungs, since the difference of sound is often slight, especially as the tympanitic sound of the stomach often mingles with the lung-sound higher up than the anatomical border of the lower limits of the lungs; moreover, the lower boundaries of the lungs close up to the spine on both sides because of the thick layers of the erector spinas, require strong per- cussion, and this is unfavorable for determining the boundaries.2 1 Compare Figs. 31 and 32. 2 See above. EXAMINATION OF THE RESPIRATORY APPARATUS. 107 FIG. 31.—Boundary of the lungs as determined by percussion in front (after Weil). g, h, the extent of the lung upward ; e,f, the lower limit of the lungs ; b, d, the relations of the lung and heart at the incisura cardiaca. The strongly-hatched surface represents the portions of the heart and liver which are parietal; the lighter hatching shows the so-called relative heart- and liver-deadness.1 FIG. 32.—Boundary of the lungs as determined by percussion upon the back (after Weil). a, b, the upper limits of the lungs ; c, d, lower limits. 1 See below. io8 SPECIAL DIAGNOSIS. We cannot determine by percussion the front borders of the lungs behind the sternum. This is the case because there the lungs lie close to each other for some distance, and also because the sternum, like a firm bone, yields a uniform sound, and it is not possible to recognize a difference of sound in what lies beneath it: it yields throughout a clear sound, very like the lung resonance over the ribs. Hence, it may also be explained that the lower part of the anterior border of the right lung, which behind the sternum is limited by the heart, cannot be defined by percussion: we much more receive, instead of the actual boundary of the right lung, one that is apparent—where the uniform sternal sound is exchanged for the absolutely deadened sound of the heart at the left border of the sternum. In front the base of the right lung does not extend so far down as the left, the right coming as low as the inferior border of the fifth rib, while the left cor- responds with the superior border of the sixth rib. Relative heart- and liver-dulness. The determination of the lung- heart and the lung-liver boundaries is made more difficult by the peculiar circumstance that, on account of the small volume of lung- tissue at the border of the lungs, the resonance of the lungs imme- diately over the borders has very slight intensity, a relatively deadened sound. We percuss from the lung toward the liver with strong or moderately strong strokes, and find, say in the mammillary line at the fifth rib, a strong relatively deadened sound which the beginner is inclined to regard as absolute liver-dulness. But this, as has been said, corresponds with the thinning of the lungs at the lower border. In this way a zone of relative dulness manifests itself over the whole of the lower border of the right lung, except close to the spine behind, and in a similar, but somewhat smaller, zone the heart-dulness bows round and to the left: this is the (incorrectly) so-called relative liver- and relative heart-dulness, as indicated by the light shading in Figs. 31 and 32. Also, sometimes, there is such a relative dulness over the lung-spleen boundary. It does not exist over the lung-stomach boundary, because here, by moderate percussion, the coincident sound of the stomach causes a low tympanitic sound. These zones are diagnostically important only in isolated cases, and they have nothing to do with enlargement of the heart, liver, or spleen. In order to avoid deception by these conditions when determining the boundaries it is necessary to take care— 1. To percuss lightly in determining the boundaries of the lungs. 2. To mark the lung-heart and the lung-liver boundary—that is, the border of the lungs where the relative dulness passes into absolute dulness, or, in other words, where, in percussing from the lungs toward the heart and the liver, the dulness begins to be so marked that it no longer increases. On the average—that is, in middle life—we thus find (compare Figs. 31 and 32) the lung-liver boundary, in the mammillary line at the sixth in the middle axillary line at the eighth, in the scapulary line at the tenth rib; the lower border of the left lung, in general as high as the right only in the mammillary line at the lower border of the sixth rib • the lung-heart boundary, at the fourth rib and more or less just without EXAMINATION OF THE RESPIRATORY APPARATUS. IO9 the parasternal line; the upper limits of the apices of the lungs, three to five cm. above the clavicle. Differences by reason of age. In children the lower border of the lungs is from a half to a whole intercostal space higher; in old persons it is that much lower (Weil). There is a like difference as regards the lung-heart boundary. That is, the lungs increase with the years as compared with other organs. Displacement of lower border of the lungs is manifest by percussion : 1. In deep inspiration and expiration (active mobility): in the mid- dle axillary line the lower border sinks with deepest inspiration about three to four cm.; in the mammillary and scapular lines, about two to three cm.; in deepest expiration it rises up not quite so much above the average location (Weil). With deep inspiration at the incisura cardiaca the lung moves so as quite to cover the heart, and it may even entirely obscure the heart-dulness. 2. In change of position (passive mobility): when lying upon one or the other side the lower border of the lung of the opposite side moves down as much as three to four cm. (Gerhardt, Salter, Weil). 3. Abnormal Sound over the I <~> vy Doubled: s d s FIG. 61.—Different kinds of division and doubling of the heart-sounds. right position and heart excited, sometimes can only be distinctly heard by placing the stethoscope at the outer left end of the apex-beat. We may especially refer a divided second sound at the apex, accord- ing to my experience, to mitral stenosis, in case there are, besides, undoubted signs of mitral insufficiency; and if at the same time the pulse is too small for a compensated mitral insufficiency, an incompen- sation is thereby excluded. Further, a divided second sound is heard in pericarditis adhasiva and systolic retraction of the apex-beat. (Friedreich's explanation of the phenomenon may be doubted.) Finally, here belongs the gallop rhythm, sometimes : or also s s s s s Fig. 62.—Gallop rhythm. that is, three similar short ringing sounds, of which either the second or third has an accent, but in many cases neither has an accent. This EXAMINA TION OF THE CIRCULA TOR Y APPARA TUS. I9I gallop rhythm may, but quite exceptionally, be observed in health with excited action (I have seen several cases). It is also observed in em- physema, contracted kidney, arterial sclerosis, heart-disease with slight incompensation. But it generally indicates severe, often fatal, heart- failure, and especially in infectious diseases. It is particularly frequent in children ; it may here—for example, in diphtheria—be the first sign of beginning paralysis of the heart, even before the pulse becomes markedly quickened. In my opinion the gallop rhythm may be explained in the same way as the divided sound, the ventricles not contracting at the same time. This question will be variously answered by different authors. Metallic Heart-sounds.—They come from the resonance of a large smooth-walled layer of air close over the heart, as is the case in pneumopericardium, not infrequently in pneumothorax, and in indi- vidual cases of large cavity in the lung with smooth walls which lies close to the heart. Intestinal or peritoneal mcteorisml or a very much inflated stomach may sometimes cause metallic heart-sounds. In pneumopericardium, also in cases of inflation of the stomach with gas, if the action of the heart is very strong or excited, the sounds may be so loud that the first, or even the first and second, can be heard at a distance. Organic Endocardial Heart-murmurs.—By endocardial heart- murmurs, as the name implies, we understand murmurs arising within the heart in distinction from those arising in the pericardium. Endo- cardial murmurs are again distinguished as organic and inorganic according as they are dependent upon anatomical changes or not. We now consider the former. Organic heart-murmurs are caused by stenosis of the openings, or by imperfect closure of the valves or insufficiency, both the ordinary and the relative insufficiency of the valves. They furnish us with an important means of recognizing the so-called valvular defects. If fluid is flowing through a tube which suddenly at a certain point is contracted, from this stenosis eddies arise in the current below that point, and these eddies will cause murmurs. If the fluid flows very rapidly, the eddies and their sounds are increased. Normally, the blood passes through the openings of the heart without sound, since there is no notable narrowing of the channel of the blood; but if an opening is narrowed, then eddies and sounds are produced, and so much the more markedly if there is compensation, when the blood from the section of the heart lying behind the narrowed opening is driven with much greater rapidity than normal through the narrowed opening.2 Such a murmur will be heard at the moment when normally the blood passes through that opening; that is, at the systole if an arterial opening is narrowed; at the diastole if a venous opening is affected (auriculo-ventricular). But insufficiency of the valves produce murmurs which are to be explained in the following way: The effect of insufficiency is such that the blood, which, in the preceding stage of the heart's action, passes through the affected opening, in the following stage, in which 1 See both of these. 2 See Preliminary Remarks, p. 168. 192 SPECIAL DIAGNOSIS. the valves of that orifice would have closed, partly flows back; it likewise flows against the blood normally flowing into the cavity, and rebounds with it; thus eddies arise and also a murmur. The intensity of this murmur depends, in the first place, upon the degree of insuf- ficiency, and, again, very materially varies with the strength of the heart's action ; for the greater this is the more marked is the difference in pressure and the more violent the backward current which it causes. Likewise, there occurs the murmur of insufficiency in that stage of the heart's action in which the affected valves ought normally to close; that is, at the arterial openings with the diastole, and at the venous openings with the systole. Moreover, it appears to me to be unquestionable that, in the great majority of cases of insufficiency, the murmur is increased by the simul- taneous occurrence of a murmur from stenosis; for the reflux current of blood certainly flows through a narrowed opening if the insufficiency is not greater than it usually is. I also think that, in connection with this, in cases of severe aortic insufficiency (N. B., with full compensa- tion), we find the diastolic murmur especially soft. (See further regard- ing this the following, upon the influences that affect the loudness and character of the heart-murmurs.) Localization of the Murmurs.—The next diagnostic point of impor- tance is that, from the location in the region of the heart where a mur- mur can be heard most distinctly or where it is loudest, we can determine whence it arises—that is, at which opening the valves are diseased. The auscultation-points already mentioned, empirically found, serve here as points of departure. W;e listen— At the apex of the heart—that is to say, at the point of the apex- beat—for the mitral valve, the left venous opening. Over the lower part of the sternum—for the tricuspid valve, the right venous opening. In the right second intercostal space, close to the sternum—for the [aortic] opening and the auricular semilunar valves. In the left second intercostal space, close to the sternum—for the opening [of the pulmonary artery] and the pulmonary semilunar valves. But it is to be noticed that the murmur caused by aortic insufficiency is, as a rule, not heard in the right second intercostal space, but is most distinct over the sternum, sometimes even in the third or fourth intercostal space at the left of the sternum ; since it is also caused by the backward flow of the blood, it is conducted in the direction of the ventricle. Analogously, but only exceptionally, the murmur of insufficiency of the mitral valves may be noticed most markedly, not at the apex, but on the left of the base of the heart; that is the case when the dilated left auricle, with its appendage, lies somewhat forward (Naunyn). The murmur of stenosis of the left auriculo-ventricular opening is often distinctly heard close to the outer edge of the apex-beat. Relation of the Heart-murmurs to the Time of Action of the Heart.__ It follows from the above discussion that the organic heart-murmurs are very closely connected with certain instants of the action of the heart, and, further, that they are divided into systolic and diastolic. And thus we hear in— EXAMINATION OF THE CIRCULATORY APPARATUS. 193 Stenosis of the aorta: A systolic murmur in the right second inter- costal space. s d s Fig. 63, a.1 Aortic insufficiency: A diastolic murmur at the same place, or, better, lower down to the left of this, over the sternum.2 s d s Fig. 63, b. Mitral stenosis: A diastolic murmur at the apex, the first sound valvular; or approximately so, if the second sound is heard at all.3 s d s Fig. 63, c. Mitral insufficiency: A systolic murmur at the apex of the heart, S D or, S D S D S D S FIG. 63, d. Quite analogously, in pulmonary stenosis and tricuspid insufficiency we hear a systolic murmur, in pulmonary insufficiency, and tricuspid stenosis a diastolic murmur at the corresponding points.4 Of these valvular defects of the right side of the heart the only one frequently present is tricuspid insufficiency, and this is relatively much more fre- quent (in great weakness of the heart) than insufficiency caused by endocarditis. Pulmonary insufficiency and stenosis are almost always congenital, and then are very often associated with a permanently open foramen ovale? Systolic murmurs in stenosis of the aorta and insufficiency of the mitral valve, and the diastolic murmur from aortic insufficiency gener- 1 [Figs. 63a, b, c, d, e,f, indicate endocardial heart-murmurs.] 2 See above. 3 See more exactly below. 4 See above. 5 Regarding this, see later. 13 i94 SPECIAL DIAGNOSIS. ally are directly joined with the sound affected by them ; but these sounds are thus always weakened, or the sound completely disappears and the murmur takes its place. In such cases the sound may still be heard if we remove the ear a short distance from the ear-plate of the stethoscope. Probably the weakened sound is not to be referred to the valve that is affected, but is conducted so as to be heard elsewhere. On the other hand, a peculiar condition commonly belongs to the diastolic murmur of mitral stenosis ; it occurs at the end of the diastole as a so-called presystolic murmur, or, if it is present at the beginning of the diastole, it becomes stronger toward the end; hence, either— or, S D S D Fig. 63, e. The explanation of this remarkable phenomenon is very simple: toward the end of the diastole the auricle contracts and drives the blood with greater rapidity through the narrow ostium venosum; hence the strengthening of the eddy and murmur. A diastolic aortic murmur maybe heard at the apex only as presys- tolic, and then, if one does not examine exactly for the other evidence, it may be taken for a mitral murmur and be interpreted as a mitral stenosis. However, when there are adhesions of the pericardium we also occasionally hear a presystolic murmur. If a presystolic murmur is very short, it may make the impression on the ear of a " tone," and the second sound.seems divided. In such cases there are difficulties in making a diagnosis.1 In most cases a little practice enables one to recognize in what period of the action of the heart an endocardial murmur belongs. But if there remains the slightest doubt whether a murmur is systolic or diastolic, then the examiner must observe the action of the heart by palpating at the same time he is auscultating, and this is best done by applying a finger to the common carotid in the neck; here the pulse is almost simultaneous with the ventricular systole, and hence demon- strates the time of its occurrence. We cannot employ the radial pulse, because it is felt too long after the systole. When the action of the heart is very irregular, and still more when it is very much accelerated, it is very difficult, or it may be entirely impossible, to distinguish between systole and diastole. DSD Fig. 63,/ 1 See p. 190. EXAMINATION OF THE CIRCULATORY APPARATUS. 195 Loudness of the Endocardial Murmurs.—From what has already been said it is evident that the loudness of the murmur is not alone dependent upon the severity of the valvular lesion. It is also a very great mistake to draw a conclusion about the degree of the stenosis or insufficiency from the loudness of the murmur; regarding this, the effects of the valvular lesions upon the heart and circulation, especially the pulse (which see), are much more determinative. Murmurs are very much affected by the strength of the action of the heart; they are plainly louder when the heart is excited, and hence when they are indistinct, if the patient is able to do so, and is not harmed by it, he can first bend forward and stretch out a few times, or he can sit up and lie down again several times in bed before we aus- cultate him. On the contrary, a murmur previously distinct becomes, without exception, more feeble if the strength of the heart declines. In very marked weakness of heart the murmur may even become entirely imperceptible; hence in disease of the heart the murmurs entirely disappear if an unfavorable turn takes place; also, they disap- pear in cases of heart-disease where the patient is overtaken with a severe febrile disease. Hence, an exact diagnosis of disease of the heart, if the heart is weak, is always uncertain, and often impossible, whenever the action of the heart is accelerated.1 Hard (calcareous) or rough valves have the effect of strengthening or sharpening the murmurs of stenosis, or, perhaps, also of insufficiency; also, in individual cases the murmur may be changed by the relaxation or rupture of the tendinous cords of the valves.2 In other respects the strength of the murmurs is dependent upon the same influences as affect the heart- sounds.3 In rare cases the heart-murmur is so marked that it may be heard at a distance, without laying the ear over the chest. Such murmurs may sometimes be perceived by the patient. The murmurs which sometimes have this peculiarity are chiefly those which arise at the aortic orifice. Murmurs differ very much in character: murmurs of insufficiency are, as a rule, softer, blowing, and, indeed, the murmur of aortic insuf- ficiency manifests itself often by its length and remarkable delicacy (it may easily be overlooked), while that of mitral insufficiency usually is louder, but not quite so long. Of the murmurs of stenosis, that of the aorta is generally loud, " sawing;" mitral stenosis, on the other hand, is almost always very soft, peculiarly rolling or " flowing," or seeming to consist of several very soft sounds. This murmur is sometimes imperceptible, even with strong action of the heart. Under some circumstances aortic or mitral murmurs of insufficiency may be musical; that is, they contain a sound which approaches a distinct, always very high musical, tone. In such cases it has fre- quently been found at the autopsy that the suspected cause of this phenomenon in such cases was a perforation of the semilunar valve, also torn floating shreds of valves, sinewy threads in the lumen of the ventricle, floating torn shreds of papillary muscle, etc. These con- 1 See Relation of Heart-murmurs to the Time of Action of the Heart, p. 194. 2 See Character of the Murmurs. 3 See these. 196 SPECIAL DIAGNOSIS. ditions generally furnish no indication as to the particular heart-lesion; it is, therefore, of no value to recognize them during life. In many cases, moreover, of which two came under my own observation, it happens that at the autopsy nothing is found to explain the occurrence of the musical murmurs during life. Metallic murmurs occur under the same conditions as metallic heart-sounds,1 in general if there is a resonant air-space near to the heart. Murmurs that may be felt: endocardial whizzing, " fremissement cataire," cat's purring. This occurs generally, but by no means always, with murmurs that are distinguished by their loudness. Locally, their most distinct perception by touch always corresponds with the loca- tions where they are heard most distinctly. W7e palpate with the hand or finger-tips and recognize thus, though only in rare cases, a fine whizzing, which is most like what we feel when we stroke the back of a purring cat. In this way, by the aid of palpation, we may prove the existence at the apex of systolic and diastolic or presystolic mitral murmurs, and in the right second intercostal space of systolic and diastolic aortic mur- murs. Defects of the right heart seldom produce murmurs that can be felt. The palpation of endocardial murmurs has so subordinate a value that we can never permit ourselves to dispense with auscultation, which yields so much sharper and clearer results. ' Transmission of Heart-murmurs.—It is understood that an endo- cardial murmur is very often not confined to that spot on the thorax where it is auscultated, but will be heard at some distance away from it. The conduction takes place especially in the direction of the blood- current. Thus an aortic systolic murmur is often heard even over the carotid in the neck. On the other hand, the diastolic aortic murmurs generally are perceived over the sternum, even louder than in the right second intercostal space; but they are also often to be heard as far down as the apex. Systolic blowing in mitral insufficiency is some- times conducted toward the right as well as farther upward. On the other hand, diastolic [presystolic] murmur from mitral stenosis is always sharply confined to the left border of the heart. An in- organic systolic pulmonary murmur which can be heard some dis- tance downward from the base of the heart very often disturbs or deceives us. Combination of Several Murmurs.—This results from the combina- tion of several valvular defects. It more frequently happens that insuf- ficiency of a valve is connected with stenosis of the opening to which that valve belongs. Then we hear at a particular spot a murmur with each of the two stages of the heart's action. It is more difficult to interpret what is heard when the disease affects different openings or valves, and especially if there are two murmurs, both of which occur with the systole (mitral insufficiency and aortic stenosis), or both in the diastole (mitral stenosis and aortic insufficiency). Then it may happen that only one valve is supposed to be diseased, and that the second murmur which is heard is transmitted from the first. But also a mis- take in the opposite direction may be possible—namely, that we assume 1 See Metallic Heart-sounds, p. 191. EXAMINATION OF THE CIRCULATORY APPARATUS. I97 that there is a combination of two valvular affections when in fact there is only one, as when a murmur of aortic insufficiency which is heard at the apex is considered as a new, independent murmur produced by mitral stenosis. The differentiation by auscultation is made in two ways : 1. By the character of the murmur. If one is blowing and the other is rough, there certainly are two murmurs; if both are alike, then there may be only one, which is conveyed from the opening where it arises to a second opening. Yet it might be that even in this case there were two murmurs, with different origin. 2. We auscultate step by step from the point where we can hear one to where the other exists, as from the apex to the aorta. If the murmur is everywhere distinct, only that toward one spot it gradually becomes louder, then it arises at this point and is conveyed to another. But if it is lost some- where on the way from the* apex to the aorta, and is again heard at the aorta, then there are two murmurs. This procedure may answer the purpose, but it often fails, and in such difficult cases auscultation alone cannot decide, but we must take a view of the whole picture of the heart and vessels in order to reach a diagnosis.1 Finally, murmurs that arise in the neighborhood of the heart may be mistaken for heart-murmurs. Those that come from the trachea and bronchi can easily be excluded by having the patient, if necessary, hold the breath. But it is more difficult to discriminate between heart- murmurs and those that have their origin in the aorta (especially aneurysm).2 Inorganic, Anemic Murmurs.3—These are so designated because they occur in all forms of anemia, both slight and severe, but especially in chlorosis, in all wasting diseases, and also in febrile diseases, without there being any disease of the heart or vessels. They serve as a sign of anemia; they generally entirely disappear with the removal of this condition. In very pronounced cases there are very soft, systolic, blowing murmurs, which are heard over the pulmonary artery or lower down with indefinite location, or they may even be heard over the apex. But not very infrequently such an inorganic murmur is also sharp, even very loud; on the other hand, it is very seldom diastolic; also we may almost say that it never is heard over the aorta. Thus the other signs of valvular disease are wanting, especially hypertrophy of a ventricle, while the pulse gives evidence of anemia, and there are murmurs in certain vessels, especially the veins of the neck. Sometimes there is at the same time considerable dilatation of the heart, as takes place in anemia;4 on the other hand, we have those marked dilatations which give rise to murmurs from relative valvular insufficiency, and which may also exist in severe conditions with which we are not at present concerned. It is very difficult to explain anemic heart-murmurs. Nothing of what has already been said regarding murmurs seems to us to be applicable here : we think, with others, that the nature of the phenom- ena differs in different cases, and in many cases we may apply Sahli's 1 P'or further on this, see below. 2 For further on this, see below. 3 Synonyms : Accidental Blood-murmurs. 4 See above. 198 SPECIAL DIAGNOSIS. supposition that venous murmurs from the large veins in the thorax lie behind these heart-murmurs. For distinguishing them from the organic heart-murmurs it is in the first place necessary to call to mind what has been mentioned as characteristic of anemic murmurs, and then to observe whether there are other signs of anemia present. Further, a valvular defect is to be excluded by the most careful examination of the heart and pulse. It is true that in many cases the phenomena are such that we can only obtain a clear idea by long observation, especially remarking whether treatment of the anemia removes the murmur. It is very difficult to decide that a diastolic murmur is due to anemia. The author recalls having seen two cases of pronounced pernicious anemia complicated with mitral endocarditis and mitral insufficiency, in both of which the differential diagnosis between anemic murmurs and the valvular disease mentioned could not be positively established during life. In both there existed simultaneously considerable emphy- sema which concealed the slight hypertrophy of the left and right ventricles. Pericardial Murmurs [Friction-sounds].—The name explains the situation of these murmurs. Their nature is the same as pleuritic friction-sounds; they are caused by the friction of the visceral and parietal pericardium made by the action of the heart when their oppos- ing surfaces rub against one another; they do this when the surfaces are rough, exceptionally even if they are simply unusually dry. The relation of the friction-sound to the action of the heart is of great importance: it occurs, not in close conjunction with the sounds, but between them, either only during the systole or more frequently in both stages, but generally louder with the first sound: s d s d s Fig. 64, a.1 More rarely, tolerably closely before and after the second sound s d s d s d s Fig. 64, b. or covering the first sound: S D S D S D S Fig. 64, c. 1 [Figs. 64, a, b, and c indicate pericardial heart-murmurs.] EXAMINATION OF THE CIRCULATORY APPARATUS. 199 Less important than the preceding is it to note that we have near to the ear a ringing, short scratching, scraping, shuffling, more rarely a creaking, sound, one which with a little practice is generally easily correctly recognized by its acoustic character. It is generally very sharply defined as to location, and is most frequently heard at the base of the heart, but often farther down at the left of the sternum. The rubbing of marked pericardial friction-sounds can be felt by applying the hand to the spot. Several special peculiarities of these friction-sounds will be mentioned when we treat of Differential Diag- nosis. Pericardial friction-sounds occur: In pericarditis, when the surfaces of the pericardium, where the fibrinous exudation exists, rub against each other without becoming adherent. Hence, we hear friction-sounds in pericarditis sicca so long as it is not adhesive, and in pericarditis exudativa if there is fibrinous exudation without enough fluid completely to keep the surfaces of the pericardium apart. This is why the friction-sound is generally heard at the base of the heart or near to it; it is not infrequently heard there as the first sign, and then often disappears as the exudation increases, and it may again return when the exudation diminishes. The disap- pearance of a previously existing pericardial friction-sound may depend upon one of four causes: 1. The complete decline of a pericarditis without any sequelae. 2. By the addition of a fluid exudation. 3 By adhesion of the pericardial surfaces. 4. From great weakness of the heart It is necessary to ascertain in every case which of these four causes is operating. If there is no evidence of the second or the fourth then the first and third must be considered; and between these it is possible to make a differential diagnosis only in very rare cases. They also occur in rare cases of tuberculosis of the pericardium (which usually results in adhesion), quite exceptionally with fragments of fibrinous cords and calcifications in the pericardium, and in abnormal dryness of the pericardium, as in cholera. The differential diagnosis between pericardial and endocardial murmurs is generally verv easy for those who are accustomed to hear both sounds, frequently by the character of the pericardial sounds and the circumstance that they sound so near the ear. Musical persons generally also immediately recognize the difference in time. But the following may enable us to distinguish between them: (a) Very much the most important is the consideration of the whole picture of the disease (form of the dulness, apex-beat, sounds, pulse, etc ^ (b) Change of Position.—The pericardial sound almost always changes, and much more than the endocardial, with change of position (c) Strong pressure with the stethoscope. If we press exactly at the right spot, especially if it be in an intercostal space sometimes the pressure very strikingly increases a pericardial sound, but never an endocardial one. But in the majority of cases, even of the former the sounds are not increased by pressure; hence it is merely confirmatory when it exists, but failure to notice it has no meaning. (d) Pericardial sounds often change their location, strength, and 1 See above. 200 SPECIAL DIAGNOSIS. character in a few hours; they may even very quickly disappear and very suddenly return.1 Endocardial murmurs are markedly chronic and regular. Very exceptionally they come and disappear suddenly if they are organic, and only in exceptional cases when due to heart- weakness. Extra-pcricardial Friction-sounds.—The friction-sounds which are heard close to the heart, and even over it, and which resemble them in sound, may be very easily confounded with the pericardial sounds. This extra-pericardial sound is, in the great majority of cases, a. pleuritic friction-sound which is caused by the contact of the pleura with the heart, especially at the lingula, and which by the mechanical effect of the action of the heart results in thrusts which correspond with the movements of the heart. It is distinguished from pericardial friction- sound in that it is greatly influenced by the breathing: it is often heard only with deep inspiration or, on the contrary, during very superficial breathing. In individual cases we hear it as pleuritic friction with strong breathing, while with quiet breathing it has the time of peri- cardial friction-sound. There occurs also a peritoneal friction with peritonitis, involving the lower surface of the diaphragm (subphrenic peritonitis), and quite exceptionally over the liver. This sound is transmitted by the motion of the heart upon the diaphragm as a pseudo-pericardial sound. The differential diagnosis of these sounds from pericarditis will de- pend upon the other signs of a pleurisy or peritonitis, and with refer- ence to pleuro-pericardial friction the effect of the breathing is to be considered. Hence the differential diagnosis may here be very diffi- cult, because sometimes a pleurisy close to the heart may by contiguity awaken a pericarditis. Fine crepitations, like those in emphysema of the skin,2 occur in the neighborhood of the heart, synchronous with the action of the heart, in mediastinal emphysema. Metallic pericardial splashing results from fluid and air in the peri- cardium (pyopneumocardiumj, exactly as we have succussion-sound with hydropneumothorax, only that the succussion is caused by the heart itself. Moreover, after the analogy of extra-pericardial friction- sound, a pseudo-pericardial—in fact, pleuritic—splashing, simultaneous with the motions of the heart, occurs with hydropneumothorax, where the motions of the heart are communicated to the fluid. This happens exceptionally, too, with large cavities which lie close to the heart. Finally, it happens that the movements of the heart produce metallic resonance or splashing sounds in the stomach. This has been observed exceptionally and temporarily in healthy people if the stomach was very full. As a permanent phenomenon it has been described in isolated cases of coalescence of the pericardium (Riess). Here it is probable that the coalescence of the heart with the pericardium, and also the eventual adhesion of the pericardium to the upper surface of the dia- phragm, may produce a more direct transmission of the beats of the heart to the wall of the stomach, or, in turn, to the contents of the stomach. Exploratory puncture of the heart is only to be undertaken with 1 See above. 2 See p. 49. EXAMINATION OF THE CIRCULATORY APPARATUS. reference to the performance of puncture, and hence belongs under therapeutics. EXAMINATION OF THE ARTERIES. Usually we select the radial pulse, which, because of its importance, requires a separate and complete consideration. Then we can add to this the description of the characters of the other arteries. I. The Pulse, its Palpation and Graphic Representation. From the commencement of medical study the radial artery has been examined where it passes between the styloid process of the radius and the tendons of the long flexors of the hand and fingers. The examination of the pulse is not a simple thing. It requires much practice, and hence it is the more important, in order to be able to recognize the differences and peculiarities of different cases, always to take the pulse at the same artery; but it is easy to understand that the radial artery is preferable because of its location, and hence it has been selected. At the same time, it is to be noted that the arteries of the forearm not infrequently pursue an abnormal course. The most frequent anomaly is of the radial artery, in that it passes across the radius out- ward and upward; or the ulnar artery may be enlarged at the expense of the radial. In the latter case, of course, the pulse of the radial is small. These anomalies may be on one or both sides. Arterial sclerosis usually influences the examination of the pulse to a very marked degree, and must therefore not be overlooked. Palpation of the Pulse.—The arm being held in an unconstrained position, we palpate the radial by making slight pressure upon it with the tips of the first and second fingers. Generally the impression is threefold: we learn the condition of the artery itself, the general state of its fulness with blood, and its pulsatory dilatation and contraction. This latter constitutes the pulse in its narrow sense. We study the pulse with reference to its frequency, its rhythm (whether the succession of beats is regular or not), and its quality. First we consider the normal pulse; then the pathological departures from it with reference to these three points of view. 1. The Normal Pulse.—Its frequency varies with the period of life. In the newly-born it varies much : when active it is as high as 140 in the minute, but during sleep it is 90 to 100. Up to the tenth year it is about 90, and at about the sixteenth year it is 76 to 70. It remains at about this number in healthy persons till old age, when it sometimes increases again to about 80 in the minute. There are variations, it is true, from these figures in perfectly healthy adults, who may continuously and regularly have a lower pulse, even down to 60 (or still lower). Sex makes a slight difference, the female average being a few beats more than the male at the same age. Moreover, the size of the body has some influence : the average of large persons is somewhat less than that of smaller persons, cceteris paribus. The daily variations in the frequency of the pulse correspond with those of the bodily temperature; the maximum is generally between 202 SPECIAL DIAGNOSIS. noon and evening, the minimum in the early morning; the difference is generally less than ten, seldom more than twenty, beats. Of about the same value is the variation of the pulse with reference to the position of the body: its frequency is highest in standing, less while sitting, and least while lying down. It varies also with the external temperature in case the latter changes considerably from the average: the lower the temperature the higher the pulse. Meals, especially of food that is rich and of hot dishes and drinks, quicken the pulse for one or two hours. Sleep has no essential effect, though the pulse rises, and generally considerably for a short time, at the moment of waking, even when this is without noticeable excite- ment. Movement of the body always increases the frequency, under some circumstances even till the frequency is doubled. Active deep breath- ing increases it. Mental excitement of any kind, as fright, anxiety, joy, joyful or painful tension, likewise quickens the pulse, but very dif- ferently in amount in different individuals according to their general excitability. All the above-mentioned influences manifest themselves with very marked variations according to the bodily constitution and the cha- racter of the nervous system [temperament]. Pale, delicate persons, who are also excitable, show the greatest increase in frequency. Dur- ing convalescence merely rising in bed, a little food, joyful or sad news, considerably quickens the pulse. In disease this is still more the case. Method of Observing the Pulse.—After excluding the temporary influences that have been mentioned, we count by the second-hand of the watch for twenty seconds; where greater exactness is required, for a half or full minute. Sometimes in hospitals the nurses employ small sand-glasses; of course their accuracy must be carefully tested. [In England and America these glasses are not used.] Sometimes in sick- ness the pulse is so frequent that it cannot be counted. It has been recommended, under these circumstances, to try to count every other beat, and then to double the result. If the radial pulse cannot be felt, or if we suspect that some beats drop out,1 we can then count while we auscultate the heart. In connection with the employment of temperature-charts we have become accustomed to note upon the chart, every time the tempera- ture is taken, also the frequency of the pulse and respiration; thus we obtain upon the fever-chart a continuous line representing the pulse, which materially aids in forming a judgment of it. (Regarding the value of this continued observation of the pulse, see below.) The rhythm of the pulse in perfect mental quiet and during quiet breathing is in health regular. But mental excitement easily makes the pulse somewhat irregular, especially in nervous persons. Again, the rhythm of the pulse is changed with many persons during deep breathing, especially, too, in nervous persons. Usually at the end of expiration and the beginning of inspiration it is quicker, while at the height of inspiration and the beginning of expiration it is slower. Normally the pulse at the two radials is exactly simultaneous; the 1 See under Intermittent Pulse. EXAMINATION OF THE CIRCULATORY APPARATUS. 203 crural pulse is also approximative^ simultaneous with the radial. But if we compare the radial with the action of the heart, we notice that it is always notably later than the corresponding systole. Regarding the quality of the pulse: the radial in health has a cer- tain general fulness and hardness, and the separate pulse-waves also have a certain size, hardness, and form. All these peculiarities ex- hibit not inconsiderable variations within the normal. Correct estimate of them by palpation is a matter of much careful practice.1 Here it is next to be remarked that in the normal pulse equality of its separate beats is desirable (equal pulse) ; only quite small, scarcely perceptible inequality sometimes occurs, again especially with nervous persons. A general symmetrical increase in the hardness of the pulse and enlarge- ment of its waves are results of physical exertion, mental excitement, etc.—in short, from anything that temporarily quickens the action of the heart.2 2. Pathological Frequency of the Pulse.—We distinguish a pulsus rarus (slow, infrequent pulse) and a frequent pulse (accelerated pulse). Care must be taken not to confound pulsus rarus with pulsus inter- mittens, in which the pulse-waves are unequal, and some of them so weak that they cannot be felt at all. With some practice pulsus inter- mittens is usually easily recognized. In some cases, however, even a more practised physician may once in a while be mistaken, as when the inequality of the heart-beat, and hence the intermittence, is periodic, so that the pauses between the palpable pulses become nearly equal. Here belong particularly pulsus bigeminus and trigeminus alternans. In case of doubt auscultation of the heart always at once removes the doubt. Of late pulsus rarus has frequently been an object of scientific investigation (Grob, Riegel). Occasion has even been taken to distin- guish it by a particular proof of respect: it has received a name. Re- tardation of the pulse, so that the number falls below 60, is called bradycardia. This name may be confounded by the hearer with the opposite, tachycardia, unless the speaker pronounces very distinctly. As a physiological phenomenon pulsus rarus appears only occasion- ally ; at least it is extremely rare in the perfectly healthy. In persons beyond the thirties it always gives rise to a suspicion of coronary sclerosis or of fatty heart, if other phenomena are entirely absent. The transition condition to the pathological pulsus rarus is that in which it occurs during the puerperium and in the state of starvation. Pathological bradycardia is found under very different conditions. The cause is partly direct or reflex irritation of the vagus center, prob- ably also irritation of the vagus trunk; partly increase of arterial pres- sure by vaso-motor or purely muscular contraction of the peripheral arteries; partly diminution of pressure by loss of blood; then indirect influences on the heart-muscle of substances circulating in the blood also come into consideration; and, finally, anatomical changes of the muscular tissue of the heart or of the endocardium. Retardation of the pulse is therefore observed— 1. In individual cases of pathological increase of the work of the heart—namely, in acute nephritis, especially the nephritis of scarlet 1 For particulars regarding the different forms of pulse, see p. 208,/. 2 See this. 204 SPECIAL DIAGNOSIS. fever. Hypertrophy of the left ventricle is often included here. But the diminished frequency of the pulse is very slight. 2. In the opposite condition of diminished pressure in the arterial system in consequence of hemorrhage, and in individual cases of febrile diseases ending in fatal collapse. 3. Sometimes with stenosis ostii aortas; here the difference is usually very slight—about 60 beats. 4. In disease of the heart-muscle, especially in fatty heart, but also in fibroid myocarditis (but here we must be on our guard not to confound it with intermittent pulse);l 48 to 36 beats are here not at all infre- quently met with. The lowest number pretended to have been observed is 8. In acute dilatation of the heart from over-exertion, whether it occurs in a diseased heart or one previously sound. 5. In old age, sometimes without any gross disease of the heart, and in marked inanition (from stenosis of esophagus, pylorus, etc.). Here, also, the slowing of the pulse may be considerable—even to 48 or less. 6. In disease of the brain or of the meninges, which results in irrita- tion of the vagus center. This may really be only mechanical, from increased intracranial pressure (tumors, hemorrhages, hydrocephalus) or from inflammatory irritation (acute meningitis, especially basilar). The slowing is considerable in the majority of cases. 7. In individual rare cases of irritation of the vagus nerve by com- pression (tumors) or by inflammation (abscess) in its neighborhood. 8. In neurasthenia, hysteria (rare). 9. In all possible, mostly painful, diseases of the abdominal organs, especially in ulcer of the stomach.2 10. In the critical decline of fever in acute febrile diseases, possibly from the effect of certain products of the fever upon the heart or the vagus center, an effect which is only manifest when the quickening effect of the high temperature upon the pulse is past.3 It is a con- siderable, but quite temporary, slowing. 11. In hepatoge7iic icterus, from the effect upon the heart of the gall- acids circulating in the blood. The pulse is diminished quite frequently as low as to 48, sometimes still lower. The slowing disappears, and is even followed by acceleration of the pulse, in persistent icterus if there develops cachexia, particularly a decrease of heart-power. 12. In certain intoxications, especially in lead and in acute alcoholic poisoning. Bradycardia occurs in a pronounced degree, but intermittently, in colic, particularly in lead colic, also in attacks of pain of other kinds, especially neuralgias; finally, in angina pectoris, not only in the so- called organic angina, notably in coronary angina (angina from sclerosis of the coronary artery), but also the nervous anginas called vaso-motor because produced by a sudden narrowing of the peripheral arteries. However, great retardation does not occur in the latter condition, but only in angina pectoris organica, especially coronaria. Frequent pulse, or tachycardia, occurs— 1. In fever, as its chief manifestation. We recognize a general 1 See this. 2 Compare bradycardia in colic. See below. 3 gee below. EXAMINATION OF THE CIRCULATORY APPARATUS. 205 relation between the elevation of the temperature and quickening of the pulse—to every degree of heat above 370 the pulse increases 8 beats above the normal (Liebermeister); but there are very great Fig. 65.—Diminution of frequency FlG. 66.—Abdominal typhus in the third to the of pulse after critical fall of temperature fourth week. The rise in the pulse corresponds in pneumonia. The unbroken line with the beginning of pneumonia. represents the temperature-curve, the broken one the pulse-curve. variations from this proportion according to the kind of febrile disease, its localization in particular organs, and, further, with the age of the patient and the strength of the heart. Thus, in abdominal typhus [typhoid fever], so long as it is not accompanied by complications, there is only a moderate quickening of the pulse; hence, in this disease a higher pulse—a pulse of 120, for instance—has a graver meaning than, for example, it has in pneumonia. This moderate quickening of the pulse peculiar to typhus abdominalis [typhoid fever] is even an aid in diagnosis in severe cases, as distinguishing it from acute miliary tuberculosis and pyemia, where the pulse is high. It has already been mentioned that in meningitis there is slowing of the pulse; when men- ingitis is added to a febrile disease, it may lower the pulse, previously quickened, to the normal, or may even bring it below the normal. On the other hand, during an abdominal typhus [typhoid fever] the addi- tion of a complicating pneumonia will, under some circumstances, be first noticed by the increased frequency of the pulse (see Fig. 66). Febrile diseases with complicating heart-disease usually have a quicker pulse than the same diseases when the heart is normal. With children the pulse is always very much higher in febrile diseases than with adults. In the course of febrile diseases the constant observation of the frequency of the pulse is of the greatest importance for estimating the strength of the heart, and with it the general vigor, or showing the 2o6 SPECIAL DIAGNOSIS. occurrence of complications, etc.1 It is also to be observed that in P. T. 200 42° 180 41 160 40 140 39 120 38 100 37 80 36 200 1885. P. T. 180 41° 160 40 140 39 120 38 100 37 80 36 ■BSE S SSSSS ■SSBSS ■■339 ■HBSHIH HH BSuSSSSI FIG. 67.—Very rapid action of the heart (mitral insufficiency). Fig. 68.—Very rapid action of the heart (convalescence from typhus; suspicion of mitral insufficiency). fever the frequency of the pulse is immediately increased by the least exertion or by excitement. In general, it is an unfavorable sign when adults have a pulse of 160 40° 140 39 120 38 100 37 80 36 Fig. 69.—Increased frequency of the pulse in fatal collapse (erysipelas). over 120, and the case requires special consideration. But when it reaches 140 it is a grave symptom. 1 On this point, see below. EXAMINATION OF THE CIRCULATORY APPARATUS. 207 Frequent pulse also occurs— 2. In different forms of anemia, especially in chlorosis. 3. In valvular disease of the heart (except only in stenosis of the aorta),1 and also even with complete compensation. 4. In heart-failure or paralysis. Thus, in the collapse of febrile dis- eases (see Fig. 69), where there is a simultaneous fall of the temperature and rise of the pulse; moreover in the arrested compensation of heart- disease, and in weakening of the heart in consequence of disease of the substance of the heart—more rarely in those cases of heart-weakness which complicate an attack of angina pectoris in organic disease of the heart. 5. With central and peripheral paralysis of the vagus. 6. In certain neuroses: Basedow's disease, traumatic neurosis, ner- vous palpitation, functional (nervous, hysterical) angina pectoris, without the nature of this phenomenon being clear. 7. In any condition of anxiety, and with severe pain. Here we have mostly to do with a frequency of the pulse which develops more or less gradually, lasts a certain time, and disappears again gradually. But in a part of the cases mentioned above tachy- cardia, and that sometimes of an extremely high degree, comes on in attacks—paroxysmal tachycardia, tachycardic fit? Such attacks are seen in the conditions mentioned under 3, 5, and 6. It is remarkable that in these attacks there may be missing not only signs of defective motive-power of the heart, but also subjective complaints, even if the attacks occur in persons with organically diseased hearts; for instance, with valvular defects. In some of the conditions named above—/. e. in anemia, in functional neuroses, and in slight diseases of the heart—it may happen that the frequency of the pulse is normal or only a little increased during rest, but is much increased in moderate exertion of the body. 3. Want of Rhythm of the Pulse.—Instead of the normal equal succession of the beats, there may be complete irregularity (arhythm); in the most marked degree this is so in mitral stenosis, even when there is perfect compensation. Moderate or marked arhythm is very frequent in myocarditis (sometimes the inequality of the pulse is here the only sign). It occurs during the stage of incompensation in all cases of heart-defect, and sometimes in all forms of marked heart- weakness. Moreover, the inequality of the pulse3 [irregularity of volume] is more important in judging of the weakness of the heart than arhythm. If in such arhythm there are individual pauses in which no pulse is felt, then we speak of " suspended" pulse, which may be pulsus deficiens —that is, the pauses indicate real pauses in the action of the heart; or it maybe a pulsus intermittens: these pauses result from weak contrac- tions of the heart, which cannot be felt as far as the radial. We deter- mine, in a given case, which of the two kinds of pulse it is by auscul- tating the heart. But there are other forms of irregularity of pulse in which the irregularity of the beats follows a rule: pulsus bigeminus, p. trigemi- nus (where two or three beats are regular and then follows a longer 1 See above. 2 Compare Figs. 67 and 68. 3 See this below. 208 SPECIAL DIAGNOSIS. pause). These forms generally indicate moderate weakness of the heart. Lastly, we must mention an especially frequent form of irregularity which stands somewhat between the two last-named forms and com- plete irregularity—the pulsus intercidens : after several perfectly regular beats, suddenly there is one that follows immediately after the last regular one (which is also always weaker), then there generally follows a slight pause. Most frequently it indicates considerable weakness of heart, and is often the forerunner of severe heart-weakness. It occurs » in valvular disease and myocarditis. In order to determine the succession of pulse-beats it is sometimes useful to employ the graphic method.1 4. Quality of the Pulse.—As has been already mentioned above, a correct judgment of the size and tension of the radial artery and of the size and form of the individual waves can only be attained by much practice. It is indispensably necessary that there should be acuteness of feeling in the examining finger, much experience of what is normal and what is pathological, and of the boundaries between the two, which cannot be sharply defined in words. The inequality of the examination must be taken into consideration, as it is affected by somewhat individual differences of the location of the arteries, the difference in the subcu- taneous fat, or as affected by arterial sclerosis. The exact examina- tion of the pulse may not be possible on account of the abnormal course of the radial artery—the most frequent variation being where the artery winds around the radius to its dorsal surface above the styloid process. We distinguish the different forms of pulse according to the follow- ing points of view: I. According to the size of the pulse: full or empty pulse, pulsus plcnus—vacuus ; a not very clear method of designation. It would be much more suitable to describe the average fulness of the artery, or, still better, its thickness at the moment of its systole—that is, in the depression between two pulse-waves. In this sense the pulse is full in almost all those cases in which it is large,2 in so far as it depends upon work of the heart, which is strong or increased. But it further depends, to a certain extent, upon the amount of blood in the system ; a certain fulness of the pulse, which in a strong person is not remarkable, in an anemic subject indicates a pathological increase in the work of the heart. Within certain limits, moreover, the difference in the fulness of the pulse is individual, being simply dependent upon the internal diameter of the arteries. We are not to confound a full pulse with a case where there is thickening of the wall of the artery by arterial sclerosis. Large and small pulse: pulsus magnus—parvus. When the work of the heart is simply increased, and still more when there is hyper- trophy of the left ventricle, the pulse is large. There is an exception to this when we have the two valvular defects in which the left ventricle, notwithstanding its hypertrophy, is able to force only a moderate quantity of blood into the aorta—aortic stenosis3 and mitral insuf- ficiency. The reason for the former is clear; the explanation of the 1 See this. 2 See below. 3 See Pulsus Tardus. EXAMINATION OF THE CIRCULATORY APPARATUS. 209 latter is that with every systole a part of the blood contained in the left ventricle flows back into the left auricle. Small pulse depends upon diminished work of the heart, upon an obstruction between the heart and the aortic system (aortic stenosis, aneurysm), and upon marked anemia. It is present in the highest deo-ree in mitral stenosis, since in this condition the left ventricle con- tains an abnormally small quantity of blood, and hence it can drive but little into the aorta. If the pulse is very small, and at the same time very empty, it is called thread-like or filiform. The trembling pulse (pulsus tremulus) is caused by a moderately full artery, in which the wave is imperceptibly small. Both are noticed when the heart is very weak. Regular and irregular pulse [as to volume]: pulsus aqualis—in- cequalis. As was previously stated, there occur in health insignificant irregularities in the individual pulse-waves. A very marked inequality is a most important sign of weak heart, more important than the irregularity which almost always accompanies it. Only in mitral ste- nosis we have a very markedly unequal (and irregular) pulse without the heart being really weak. Often, too, there exists in a measure a condition between inequality and irregularity, as follows : A pulse follows the previous one with a shorter pause, then after a longer pause there is one with a stronger beat. Especially in pulsus intercidensx the between-beat that immedi- ately follows a pulse-wave is always small. Pulsus alternans is so called when a larger wave alternates with a smaller one. At the same time it is generally bigeminous.2 We call a pulse pulsus paradoxus which has the peculiarity that in deep breathing, toward the end of inspiration, it becomes weaker or is once or more times omitted. It is an important sign of pericarditis adhcesiva with fibroid mediastino-pericarditis, and it arises from the bending or traction of large arterial branches as the thorax is broad- ened in the act of inspiration and the diaphragm is pressed down. 2. We distinguish the form of the pulse-wave as quick or slow, pulsus celer—tardus. Here also belongs the pulsus dicrotus. In the quick pulse the artery quickly enlarges, and immediately becomes narrow with a like quick contraction. But with a slow pulse the enlargement and contraction are slower than normal, and the artery also lingers in the diastole during a portion of time which a trained finger may recognize. With the quick pulse the examiner notices that the stroke is very short, while in the latter it is more a pressure in the vessel against the palpating finger. Every pulsus magnus may exhibit a moderate celerity. Only m aortic insufficiency is the pulse decidedly quick. It is a miniature pict- ure of the large fluctuations of pressure in the aorta which quickly follow one another, as with every systole it receives from the dilated and hypertrophied left ventricle an abnormally large quantity of blood, which it immediately disposes of in two directions—sending part back again into the ventricle, and part forward into the body. It is remarkable that also in heart-weakness there is sometimes a light, quick pulse. It is true that it is always very easy to compress 1 See above, p. 208. 2 See this> P- 207/ 14 210 SPECIAL DIAGNOSIS. it, and between the pulse-waves the walls of the artery fall together very decidedly (pulsus vacuus, and at the same time celcr). Pulsus tardus is an especial peculiarity of aortic stenosis, and at the same time it is generally smaller than normal. How much it may be diminished in size depends upon the degree of stenosis and the strength of the heart. Pulsus tardus occurs also with arterial sclerosis, likewise with lead colic, but also sometimes with other colics, as well as in peritonitis. Pulsus dicrotus will be more exactly described with the Sphygmog- raphy of the Pulse.1 3. According to the hardness of the pulse (tension of the arterial wall) we distinguish hard or tense and soft pulse, pulsus durus (tensus) —mollis. Here we must especially guard against confounding it with arterial sclerosis, which imparts to the wall of the vessel a hardness which has nothing to do with its tension. We test the hardness of the pulse by endeavoring to compress it with the finger. // is easy to compress a soft pulse. Again, it is really the power of the heart that produces these pecu- liarities, as well as the active tension of the wall of the vessel. In heart-weakness the small pulse is also always a soft pulse; the large pulse is likewise often hard. With pulsus tardus there is almost always a strong action of the heart, and if the heart is hypertrophied, the pulse at the same time is often hard. When the pulse is quick there are constantly marked variations in its hardness. The hardness of the pulse is especially characteristic in contracted kidney with hypertrophy of the heart, also in lead colic (" wire pulse "). The pulse is tense also in apoplexia cerebri and in commencing menin- gitis, no doubt from irritation of the vaso-motor center. V. Basch has constructed a so-called sphygmomanometer, which is very useful for measuring exactly the tension in the arterial wall, and thus the blood-pressure. It has been brought out again lately, altered in construction.2 We omit a description of the apparatus and its mode of use, since each instrument is furnished with directions for using. We only remark that, in our opinion, it should be exclusively applied on the arteria temporalis, because here alone the conditions of the experiment are somewhat equal. And even here the apparatus very often indicates too low a blood-pressure. Normally, the pressure is 80 to 110 mm. of mercury, and the range of values indicated by the instru- ment in healthy persons is much greater than corresponds to the variations of the arterial pressure. For this reason the instrument does not seem to be adapted for ascertaining the absolute height of pressure. But it is very practical for ascertaining the variations of pressure by continual observation on one and the same patient, if care is taken always, as far as possible, to make the conditions of the experiment equal. Of these the most important is to mark with color or a light line of nitrate of silver the exact portion of the temporalis on which is placed the so-called pulse-cap. 5. Symmetry of the Radial Pulse.3—As has been already men- tioned, apart from anatomical variations of the artery upon one side, the pulse upon the two sides is perfectly alike as to time and quality. 1 See p. 214. 2 G. Lufft, Eberhardtstrasse, Stuttgart. 3 Compare p. 216. EXAMINATION OF THE CIRCULATORY APPARATUS. 211 It may be disturbed, even to complete absence of the pulse upon one side. Ewald has found that the difference between the two radial pulses under some circumstances is made more distinct by raising the arm. Inequality is caused— i. By surgical diseases of the arm, as fracture of the bone, injuries or operations which displace the radial or which result in narrowing, compression, or cicatricial contraction of the radial, brachial, or axillary artery: in which case the pulse upon that side is found to be smaller. 2. By tumors of the chest-cavity, of the supra- or infraclavicular fossa, or of the axilla, which press upon the innominate, subclavian, or axillary artery of one side. They weaken the radial pulse even to complete obliteration. 3. By aneurysm of the aorta, innominate} also by aneurysm of the subclavian, axillary, and brachial (all very rare).2 4. By emboli and autochtonous thrombi toward the center from the location of the pulse. In this case the pulse is commonly entirely wanting. 5. In pneumothorax, also large pleuritic exudation with compression and distortion of the subclavian. Sometimes the pulse upon the affected side is smaller, also frequently later. Sphygmography of the Radial Pulse. K. Vierordt originated the idea of sphygmography. With continued improvements of the apparatus the idea has been further developed by Marey, Wolff, Landois, Sommerbrodt, Riegel [and others]. Sommerbrodt's sphygmograph is the one now most generally used, but it has defects. Recently Ludwig has very decidedly improved upon Marey's instrument, as it seems to me. It can be obtained from Petzold, instrument-maker in Leipzig. [The instrument devised by Dr. Richardson of London is, in the opinion of the Translator, the most practically useful one yet brought out.] I am very much pleased with the sphygmograph of Jaquet (of Basle), which has a rest for the arm and a mechanism for measuring the time, and a twofold velocity. It fulfils every requisition that can reasonably be made with reference to sphygmography when the instrument is applied to the artery in its normal condition. The instrument can be very highly recommended. By others the sphygmograph of v. Frey (made by Petzold of Leipzig) is preferred, but I am sorry to say that I have no means of forming a personal judgment of it. What the sphygmograph really measures is the pressure of the pulse in the respective arteries. Therefore the instrument is only a refined [and recording] means of palpation. But it must be here emphasized that an absolute measure of the size of the pulse or of the internal pressure of the artery cannot be obtained in this way, as the height of the pulse-waves varies greatly with the position of the apparatus with reference to the artery and the position of the pad which receives the pulse. Hence it is well not to pay any attention at all to the height of the pulse-waves, but only to observe their form. 1 In what way, see p. 219. 2 See works upon Surgery. 212 SPECIAL DIAGNOSIS. In health the pulse-curve obtained with the sphygmograph shows elevations and depressions, ascending and descending lines, correspond- ing with the expansion and collapse of the artery. The expressions " apex-curve " (eg) and " curve at the base " (b) do not need further explanation. At both these points the curve stops only a very small portion of time. The ascension line (al) is almost perpendicular; that is, the rise follows very quickly. The descent (a) is more drawn out and shows several small waves, which generally (not always) may be distinguished as a marked elevation (r), the backward-stroke elevation, caused by a wave of blood which results from the closure of the semilunar valve, and two (sometimes also three), or only one weaker, elevation produced by elasticity (e); the elastic secondary oscillation of the wall of the artery (according to Landois, but otherwise explained by others). The elevation (r), the " recoil," has hitherto been regarded as a positive centrifugal wave due to the closure of the aortic valves. Recently v. Frey and Krehl have come to the conclusion that this explanation is not tenable—that the question in the " recoil elevation " is rather with reference to a centripetal wave which is reflected by the peripheral end of the circulation of the body, as by the closed end of a tube.' The opinion formerly expressed that r was more marked the nearer we were to the heart would then probably have to be explained by saying that it was the summation of the waves which originate in various individual arterial regions, and are thence reflected. But this view has met with strong opposition, and we too cannot avoid sharing in the opinions which have been brought against it, par- ticularly by Hiirthle, and are rather inclined to return to the old opinion. However that may be, the quality of the " recoil elevation" has this diagnostic value: it increases with the diminution of the tension of the artery; its presence or absence, and in the former case its size, forms in itself a certain measure for judging of the blood-pressure; likewise, but in a reversed sense, when the " elasticity elevations " are very pro- nounced we must assume that there is considerable pressure. It is to Fig. 70.—Normal pulse-curve in a healthy man, aged twenty-five years (after Eichhorst). be remarked regarding the sphygmography of other arteries that r becomes more marked the nearer we go to the heart. The following are the essential pathological forms of sphygmographic pulse-waves: 1. A descending line with several very marked elasticity elevations, but smaller backward-stroke elevations (often difficult to make out) which correspond with the increased tension in the aortic system (lead colic, contracted kidney, acute nephritis, etc.). EXAMINA TION OF THE CIRCULA TOR Y APPARA TUS. 213 2. On the other hand, diminution of the elasticity elevation with more marked backward-stroke elevation shows diminished blood- pressure. Such increase of r is called " dicrotic," and the pulse " dicrotic pulse." Such a pulse, even if it is only moderately pro- Fig. 71.—High-tension pulse. nounced, can be recognized by palpation. It occurs in certain condi- tions which accompany a moderate diminution of strength of the heart, but especially a diminution of the tone of the arteries: a. In acute febrile diseases, and indeed in so marked a degree and so early in typhus abdominalis [typhoid fever] that in diagnosis we may attach some, though not too great, value to this symptom. b. In chronic wasting diseases, especially febrile—more than others in tuberculosis. Here, according to my observation, it is not infre- quent. c. In other weak conditions, as after great loss of blood, and in general in all forms of anemia. Ljwwwvy Fig. 72.—Different forms of dicrotic pulse (after Eichhorst). The above curves show that in the dicrotic pulse the backward- stroke elevation may fall in the descending line (subdicrotic pulse), as well as in the middle of the basis curve (complete dicrotic pulse), likewise in the ascending line of the next following wave (superdicrotic pulse). The so-called monocrotic pulse (no visible backward-stroke elevation) is a sort of superdicrotic pulse. 214 SPECIAL DIAGNOSIS. Wrhat has been said in general regarding dicrotic pulse expresses the diagnostic value of all these forms of pulse. 3. To the pulsus celer corresponds a curve with a very steep ascend- ing line and an unnaturally high apex-curve (in consequence of the quickness of the arterial diastole the recording lever of the apparatus is always thrown too high up). Moreover, the apex-curve is sharp- pointed, and the descending line is almost as steep as the ascending line. The elasticity elevations are marked. With pulsus celer due to aortic insufficiency there is, of course, no backward-stroke elevation, as the semilunar valve does not close.1 Fig. 73.—Pulse-curve in aortic insufficiency (after Striimpell). 4. Pulsus tardus, as in palpation2 so in the curve, is the exact oppo- site of the preceding. With it there are usually more complete loss of the elasticity elevation and indistinct backward-stroke elevation. FIG. 74.—Pulse-curve in stenosis of the aortic orifice (after Striimpell). A peculiar combination of pulsus celer and tardus manifests itself with insufficiency and stenosis of the aorta. In pulsus tardus the quickness of the apparatus is completely want- ing on account of the slowness of the ascension; hence it always seems Fig. 75.—Pulsus tardus in atheroma of the arteries (after Eichhorst). small in comparison with the normal pulse-wave, and with that of pulsus celer3 still smaller than is really the case. It is quite impossible to form an estimate of the size of the pulse 1 Compare what has been said on p. 209 upon Pulsus Celer. 2 See p. 209. 3 See this. EXAMINATION OF THE CIRCULATORY APPARATUS. 215 from the sphygmographic curve. The unequal pulse will generally be very beautifully delineated by the apparatus, but it cannot be more exactly depicted than it can be learned by exact palpation. It is true FIG. 76.__Pulse with anacrotic elevation in aortic insufficiency, with moderate stenosis of the orifice and arterial sclerosis. that the apparatus includes small waves that the finger cannot recog- nize, but often these cannot be distinguished from the elevations indi- cating the backward stroke. FIG. 77.—Pulse-curve with marked mitral stenosis (after Striimpell). The rhythm of the pulse will, of course, even if only for a very short distance, be very well exhibited, and it is in this direction that the graphic delineation is very useful in giving instruction. But here sphygmography is wholly wanting for diagnostic purposes, since every notable useful irregularity can be felt just as well. Annexed is an example of pulsus bigeminus (after Riegel). Fig. 78.—Pulsus bigeminus (after Riegel). The application of the sphygmograph to both radial arteries simul- taneously and comparison of the records will sometimes markedly increase the discrimination with reference to the symmetry of the radial pulses. Recently v. Ziemssen has shown that if the left subclavian artery is narrower at the point where it is given off from the aorta, the radial pulse of that side is very decidedly changed. He shows oblique lines of ascension, lowering, and retardation of the summit of the curve and monocrity, as is apparent from the accompanying figure. Von Ziemssen designates this as pulsus differens in the narrower sense. This corresponds, as has been stated, with a narrowing of the subclavian at its origin, and it will be found in aneurysm of the arch of the aorta if associated with a stenosing endarteritis of the origin of the subclavian or a dragging of this vessel, or, finally, with compression of the commencement of the left subclavian artery. We may also expect to have the pulsus differens in compression of the left subclavian by any sort of tumor, by pneumothorax, and by a very large pleurnic 2l6 SPECIAL DIAGNOSIS. exudate. Aneurysmal dilatation of the aorta by itself—that is, without stenosis of the subclavian—does not seem to give rise to this pulse.1 FIG. 79.—Pulsus differens: Aneurysm of aorta with stenosis of the mouth of left subclavian artery (after von Ziemssen). Diagnostic Value of the Examination of the Pulse. From what has been said it is sufficiently evident that for the pur- poses of diagnosis palpation of the radial pulse is preferable to sphyg- mography. The latter is more circumstantial, and gives, with a few exceptions, to one sufficiently practised in palpation no better result than the former. It very easily even deceives, especially regarding the size of the pulse, but sometimes also its form, from reasons that lie in the apparatus. Except in individual cases—as, for instance, when this question is in regard to pulsus differens—the great value of the sphyg- mograph for the clinician consists chiefly in its usefulness in giving instruction, for exhibiting a characteristic anomaly of the pulse to a large number of hearers, or it may serve to show a pupil what he ought to feel. In what follows will be briefly indicated in which direction the examination of the pulse is of value for diagnosis, and how it can be turned to account: 1. Very often the pulse directly serves to determine the diagnosis— not that it alone is sufficient, but in connection with other phenomena it is. We are to bear in mind here what has previously been said regarding the behavior of the pulse in the various febrile diseases. But in diseases of the heart it especially has such an important place that a diagnosis is never to be made without taking into consideration the condition of the pulse. In what follows is brought together what can be said regarding the behavior of the pulse in the most important of the diseases of the heart Mitral insufficiency: The pulse does not markedly or notably vary from the normal. But in addition the signs of hypertrophy of the right and left ventricles are present—systolic murmur at the apex. Mitral stenosis: In classical cases, even with good compensation, pulse is small, unequal, or irregular, its frequency often much increased! Indeed, not infrequently these pulse signs are absent, and the pulse does not to any great extent depart from the normal. (In addition, 1 Compare further p. 211; also p. 218 / Aneurysm of Aorta. EXAMINATION OF THE CIRCULATORY APPARATUS. 217 there are signs of hypertrophy of the right ventricle and a presystolic murmur at the apex.) Aortic insufficiency: Pulse is quick, frequency either normal or in- creased ; generally equal and regular. In addition there are the signs of hypertrophy of the left ventricle and a diastolic blowing murmur at the aorta. (For the conditions at certain arteries, etc., see below, page 220 f.) Stenosis of the aorta: Pulse is small, slow, normal or diminished in frequency, equal and regular. In addition, there are signs of hyper- trophy of the left ventricle; only the apex-beat is often very strong and a systolic murmur heard over the aorta. Myocarditis: Pulse is more or less small and soft, almost always irregular in quality, and generally so in time (here especially we have sometimes pulsus incidens, bigeminus). Frequency is increased, nor- mal, or diminished. Nothing abnormal at the heart, or signs of dila- tation of one or both ventricles; no murmurs. Pericarditis exudativa: Pulse is strong if the heart remains so, gen- erally somewhat quickened. In addition, at the heart all signs of its activity are diminished or removed by being covered over, marked dulness; in paralysis of the heart no pulse or very much quickened; sometimes pulsus paradoxus. We are particularly to notice the opposite condition of the pulse in aortic insufficiency and stenosis, and also that in myocarditis the pulse may be the only sign. In combined valvular disease the pulse is of importance in two ways : it betrays the existence of a second valvular disease besides the one already made out, as is especially the case in mitral insufficiency and stenosis. The latter near the former may be overlooked because very slight, or may even be entirely wanting, and because it produces hyper- trophy of the right ventricle, which is also produced by the former, for there may be a very small, unequal, irregular pulse, which alone indi- cates the stenosis. Also, an aortic stenosis, besides insufficiency of the aorta, is sometimes certainly discovered only by the pulse, since there may be a weak systolic murmur at the aorta without stenosis. Thils the decision as to which cardiac orifice is concerned in the murmur, or whether we have one murmur widely conducted or two murmurs inde- pendent of each other, may be determined by the pulse. Moreover, in a patient with combined valvular disease the pulse may very greatly assist in determining which disease is to be regarded as the more marked or important. This is especially true in insuf- ficiency and stenosis of the aorta (the distinctness of the murmurs is, of course, not at all indicative;l also of the mitral or for combined disease of the aortic and mitral valves. Thus we would diagnosticate a preponderating insufficiency and a very slight stenosis of the aorta when we have the signs of hyper- trophy of the left ventricle, a loud sawing systolic and a very slight diastolic aortic murmur, and a pronounced pulsus celer. Thus, with the signs of aortic insufficiency and mitral stenosis a very small pulse points to the preponderance of the latter. It is very difficult or even impossible to make a diagnosis of the 1 See above. 218 SPECIAL DIAGNOSIS. particular heart-lesion, either from the general symptoms or from the pulse, so long as there is continued evidence of incompensation. Moreover, in the cases where the heart and its action are concealed, especially in pericarditis exudativa, also in emphysema, sometimes in marked deformity of the thorax, displacement of the heart, tumors of the chest-wall, the pulse is the only sure sign of what work the left ventricle is doing. In pericarditis the contrariety that exists between a diminishing apex-beat, the slight, almost imperceptible heart-sound, and a strong pulse is sometimes a very important diagnostic point. 2. The pulse enables us to judge of the strength of the heart in all other possible—especially febrile—diseases. Even the first examination of the pulse furnishes, in this case, important information; but the signification of indications furnished by repeated examinations of the pulse (palpation and representation of its varying frequency upon the temperature-chart) becomes very much more valuable. These indica- tions furnish still more important diagnostic points, some of which have already been spoken of. They have reference to the beginning of complications in acute infectious diseases, especially those affecting the heart, the lungs (which are very frequent), the kidneys (as after scarlet fever, when the pulse has greater tension and diminished fre- quency), and to the brain (decline in frequency in meningitis). Also, the effect of treatment, as of cold baths, may be determined partly by the behavior of the pulse; in general, it often determines the treat- ment. We must also mention all diseases which in any way affect the heart, as pleuritis, pericarditis, peritonitis, in which the pulse, especially as a measure of treatment, has any part. II. Other Phenomena in Arteries, The Aorta.—Sometimes a pulsation is to be seen and felt in the neck: exceptionally also in health in consequence of higher location of the arch of the aorta; likewise in hypertrophy of the left ventricle, most marked in aortic insufficiency, since this causes a broadening of the commencement of the aorta ; and, finally, in aneurysm of the arch of the aorta. The occurrence of pulsation that can be seen and felt in the right second intercostal space is always pathological. It occurs in hyper- trophy of the left ventricle, and also especially in insufficiency of the aorta; further, in aneurysm of the aorta. In rare cases, when there is marked hypertrophy, the second aortic sound may be felt, which, of course, can never be the case in aortic insufficiency. In rare cases of aortic insufficiency the commencement of the aorta is accessible for percussion. It is to be remembered that here it is very much broadened, and to the right of the sternum, from the lower border of the second rib to the third rib, there is a small area of dul- ness. Sometimes over the aorta (in the right second intercostal space) in marked atheroma there ought to be heard a systolic murmur, even when there is no endocarditis aortica. Aneurysm of the aorta requires a special description. It most frequently occurs in the ascending portion or the arch of the aorta, and EXAMINATION OF THE CIRCULATORY APPARATUS. 219 gives rise to the following phenomena: Only when the aneurysm is large is a swelling to be seen, and this, if present, is seen either above the sternum or close to the right of it. It generally pulsates—that is, becomes larger in all directions—with the systole of the heart. From stagnation1 the enlarged veins of the skin are very early visible; later they may become red from inflammation or even be necrotic. In large aneurysm, under some circumstances, when we palpate we feel the pulsation, and besides, not infrequently, a peculiar whizzing or thrill. With large tumors, also, it further shows that the bones and cartilages over them have been absorbed. Repeated measurement of the thorax shows a gradual increase of the sterno-vertebral diameter. Percussion generally very early exhibits dulness, usually on the right, close to the sternum and over the manubrium; more rarely to the left of the ster- num, and this either in connection with the area of heart-dulness or dis- tinct from it. Auscultation not infrequently reveals the systolic whizzing, which has already been referred to as being felt, or also only two dull, impure sounds, or they may not be heard at all. The radial pulse, also the carotid, is not infrequently at an early stage upon one side smaller and a little later than on the other, in consequence of the compression of the particular branches of the aorta or distortion of their openings at the point of origin. Aneurysm of the ascending aorta affects the vessels of the right side, and aneurysm of the arch of the aorta some- times affects those of the left side.2 Not infrequently also there exists insufficiency of the aorta with hypertrophy of the heart. By all tumors in this neighborhood the heart may be crowded toward the left side.3 Aneurysm of the innominate produces about the same local symp- toms as aneurysm of the ascending aorta, only generally somewhat higher up. Aneurysm of the descending aorta (rare) may produce corresponding phenomena upon the left side, posteriorly, near the spine. The pulse in the abdominal aorta and its branches is usually later. Aneurysm of the abdominal aorta (likewise rare) is generally at the level of the tripus cceliacus. It may be felt as a pulsating tumor in the upper part of the abdomen, and sometimes exhibits the whizzing mentioned above. Considerable stenosis, or even closure, of the aorta at the junction of the ductus arteriosus is a very rare congenital condition, which is rec- ognized by the fact that certain arteries furnish collateral circulation between the ascending aorta and the region of the descending thoracic aorta or the abdominal aorta. These collateral vessels become very much enlarged, and pulsate so as to be seen and felt. Diagnostically, the most important are the internal mammary, the anterior superior and inferior epigastric anteriorly, the transversus scapulae and dorsalis posteriorly. The Pulmonary Artery.—In very rare cases aneurysm of the pulmonary artery may give rise to almost the same symptoms as aneurysm of the aorta, except in being at the left of the sternum; that 1 See p. 224. 2 Compare Pulsus differens, p. 215. 3 See further, under Examination of the Larynx, regarding the evidences of pressure by these tumors upon the trachea, upon the esophagus, upon the left recurrent nerve (seldom the right). Regarding pressure upon the large veins, see p. 224. 220 SPECIAL DIAGNOSIS. is, if it is a question whether there is aneurysm of the pulmonary artery. A systolic murmur over the pulmonary artery may, besides, be caused by stenosis of the pulmonary opening or by narrowing of the artery itself. This may be congenital or be developed later, in the latter case by shrinking of the upper portion of the left lung. In such cases the second pulmonary sound is generally accentuated (hyper- trophy of the right ventricle), and under some circumstances may even be felt.1 The Other Arteries.—Inspection.—Excepting during excitement of the heart (by mental excitement or physical exertion) we observe in health a visible pulsation of the carotid in the neck just under the angle of the jaw; also of the temporal artery. A marked pulsation of the carotid—especially when there is perfect mental and physical quietude, or, again, a general visible pulsation of smaller vessels, as of the temporal, the brachial, in the sulcus of the brachial muscle or at the bend of the elbow, of the radial, peroneal, dorsalis pedis—points to hypertrophy of the left ventricle. These abnormal pulsations are most marked in insufficiency of the aortic valves and in arterial sclerosis; in the first case on account of the fulness of the pulse, in the latter case on account of the thickened and stiffened vessels being prominent. In both classes of cases the smaller arteries are very tortuous. Here also a capillary pulse is to be mentioned: alternating between marked fulness and emptiness of the capillaries, occasioned by the pulse in the arteries, the pulse may become visible under the finger- nails, more rarely over the tendons, in case these variations are con- nected with a large and quick pulse in the arteries, which, in turn, have large and quick alternations of size. Then, in examining the finger- nail, we see the red part rhythmically become alternately white and red—capillary pulse of the bed of the nail? This is a sign of aortic insufficiency with marked hypertrophy of the left ventricle (which would also be present in some cases of marasmus). Palpation.—Medium-sized and small arteries sometimes feel thick- ened and moderately stiff, or scattered in their walls we feel separate rigid patches, very like the plates of cartilage of the bronchial tubes or the rings of a small trachea (" goose's throat"). The latter become especially plain if we slip the tip of the finger up and down along the course of the artery. This is the condition in arterial sclerosis. Hence the vessels are often tortuous3 and show variations of the pulse.4 It is very easy to recognize arterial sclerosis in the temporal, radial, and brachial arteries. From the condition of these we can correctly esti- mate the condition of other arteries of the same size. Palpation of the radial artery has already been described. Of the other arteries of the extremities the pulse of which we can feel in health, we may mention the brachial, in many persons the ulnar, the crural, the popliteal, and in most people the peroneal. Increased pulsation in arteries that can be felt, its occurrence in small arteries 1 See above. 2 [This is often an unfavorable situation for making the observation. Quincke, who first described the capillary pulse, now recommends rubbing gently a spot upon the forehead. —Berliner klin. Wochenschr., Mar. 24, 1890.] 3 See above. * See this. EXAMINATION OF THE CIRCULATORY APPARATUS. 221 that can be felt, which in health are never made out, takes place in aortic insufficiency. A pulsation that can be felt in the dorsalis pedis artery is here very frequent, but the same thing may take place in still smaller arteries—in the digital, in the coronariae labii inferior., superior., and the like. Very exceptionally in aortic insufficiency we may even observe an arterial liver-pulse; that is, a continuous to-and-fro swell- ing of the liver from the marked pulse in the arteries of the liver (quite like the venous liver-pulse).1 Still more rare is an arterial pulse at the spleen.2 When in symmetrical vessels, like the two radials, we find a pulse that is unequal as to strength or time, we may generally conclude that there is a mechanical hindrance to the passage of the blood-current. We then have to seek toward the center from the weaker or later pulsating artery for a compressing tumor, thrombosis (autochthonous or embolic), or for an aneurysm. Moreover, there are observed variations of the pulse in symmetrical vessels, caused by vaso-motor influences from the nerve-centers. Finally, we must not overlook the possibility of anatomical variations. Auscultation.—Mode of procedure: Here, it is to be understood throughout, the stethoscope is to be employed, and that ordinarily it is to rest upon the surface without pressure. We auscultate the carotid with the neck somewhat extended, but not stretched, in the intersterno- cleido-mastoid fossa or at the angle of the jaw; the subclavian, in the angle between the clavicle and the clavicular head of the sterno-cleido- mastoid muscle; the brachial, on the inner border of the biceps in the bend of the elbow, with the arm slightly extended; the crural, close below Poupart's ligament. Normal Condition.—In health we usually hear over the carotid, as well as the subclavian, two sounds—one corresponding to the pulse, with the systole of the heart (the conducted aortic first sound and local diastolic sound in the vessel). In individual cases the first sound is impure or is entirely wanting. In health the diastolic heart-sound is never wanting. We sometimes hear over the abdominal aorta and the crural artery a sound which corresponds with the pulse, or, at any rate, arises locally from the tension of the vessels. We usually hear nothing over any of the small vessels. If we press with the stetho- scope over the given vessel, then we hear the so-called acoustic pressure-sound, not alone over the aorta and subclavian, but also regularly over the abdominal aorta and crural artery, and usually, also, over the brachial. Thus, by moderate pressure over these vessels we hear a pressure-murmur corresponding to the arterial pulse; by stronger pressure, which almost, but not quite, closes the artery, this murmur is changed into a tone—pressure-tone. That these acoustic phenomena, resulting from pressure, are everywhere present are the chief reasons why the pathological conditions over the large vessels which are to be mentioned later have only conditional diagnostic value. We must also mention a phenomenon frequently present in healthy children, called " cerebral blowing;" it is heard between the third month and the sixth year with the systole of the heart, or, more exactly, as a blowing corresponding with the carotid pulse, which is 1 See p. 228. 2 See under Examination of the Spleen. 22 2 SPECIAL DIAGNOSIS. heard sometimes light, sometimes tolerably loud, over the fontanelle while still open, but also sometimes after it has closed, and elsewhere over the head. Jurasz has in most cases found at the same time a blowing over the carotid, and thinks that the cerebral blowing is merely this murmur conducted upward. He explains the latter by the compression which the carotid sustains in the carotid canal during the development of the skull. Pathological Conditions.—In aortic stenosis there will be heard over the carotid, in place of the first sound, a rough systolic heart- murmur (the stethoscope must rest very lightly). In aortic insufficiency the second sound of the carotid and sub- clavian is wanting, or it is replaced by blowing with the diastole of the heart (rare). This, as well as the systolic murmur previously men- tioned, is conducted from the mouth of the aorta. The former, arising in a current of blood flowing forward, would naturally, as a rule, be more loudly conducted than the latter, which comes from a backward-flowing blood-current. Sounds in such arteries as in health very seldom or never furnish a sound accompany aortic insufficiency, being produced by the quick and strong tension of the vessels during their diastole. We then hear a sound corresponding with the pulse over the crural, brachial, radial, even the ulnar, peroneal, dorsalis pedis arteries; sometimes even over still smaller vessels. A sound is also observed over the crural in high fever, as well as in anemia and chlorosis (and as well in some healthy persons). A double sound over the crural artery (Traube) is heard in indi- vidual cases of aortic insufficiency. But this phenomenon has also, although very exceptionally, been observed with mitral stenosis (Weil), likewise in lead-poisoning (Matterstock); lastly, in pregnancy (Ger- hardt). Much more important is the double murmur which is heard when considerable pressure is made with the stethoscope—Durozicz's double murmur. In the experience of observers, thus far, this occurs only with aortic insufficiency, and this when there is good compensa- tion ; and this has all the greater significance from the fact that it is decidedly more frequent than was previously supposed. Double sound, as well as double murmur, can only occur when there is a large and quick pulse. In the first phenomenon the double sound is caused by the sudden collapse of the artery ; with double murmur the second murmur is probably to be explained by the short reflux blood-current which may be assumed to flow into the large vessels when there is aortic insufficiency (?). A double sound can also be heard over the crural artery if one of the two sounds, or even if both sounds, arise from the crural vein.1 A systolic subclavian murmur is sometimes heard on both sides, or sometimes only on one side (especially the left), as a very disturbing addition to the breath-sounds at the apex of the lungs. It is stronger, or perhaps only to be heard, toward the end of inspiration. When it occurs upon both sides, as a rule, it does not indicate a pathological condition; when unilateral, it also has no significance, and yet it always gives the suspicion of phthisis, with which we often meet it. It is ex- 1 Regarding this, see next chapter. EXAMINATION OF THE CIRCULATORY APPARATUS. 223 plained by a temporary pulling or bending, and hence narrowing of the subclavian artery during deep breathing. In phthisis this is caused by adhesion of the pleural surfaces at the anterior surface of the apex of the lungs. We do not know exactly why this murmur occurs also with persons apparently perfectly healthy, but it may possibly be from the same cause. Loud blowing murmurs over the thyroid glands sometimes occur in all forms of struma. These murmurs may be felt. They are not in- frequent with struma of Basedow's disease, but here they are caused by the excited action of the heart. The murmurs which in some cases are heard over aneurysm have been already mentioned. EXAMINATION OF THE VEINS. We examine chiefly, in many cases exclusively, the jugular veins (external and internal in the neck), but also the cutaneous veins of the body and extremities. Only in special cases (thrombosis) do the deep veins of the extremities become accessible for examination. The ophthalmoscopic examination of the ophthalmic veins does not come within the scope of this book. It is important that we are able to judge of the abnormal fulness (engorgement) of certain deep veins by its effect upon particular internal organs, as enlargement of the liver and spleen, also ascites, and, lastly, the suppression of urine.1 The examination of the veins is made by inspection, or sometimes by palpation and auscultation. Inspection and Palpation of Veins. By these means we ascertain the degree of fulness, the condition of the circulation, and, under some circumstances, the existence of venous thrombosis. An unusually empty condition of the veins does not come under consideration. This would also be very difficult to determine, for the reason that even in health, especially in fat people, the super- ficial veins may be indistinct or entirely invisible. It remains to describe—1. Increased fulness of veins; 2. Circulation in the veins of the neck; 3. Circulation in the other veins ; 4. Venous thrombosis. 1. Increased Fulness of Veins.—This is the result of stoppage of the blood in its course toward the centre. It is general or local according to the cause of the engorgement, whether this be central or at some place in the course of the nerves that control the circulation. General increased fulness is the result of general venous engorge- ment. We first recognize it by the swelling of the internal and exter- nal jugular veins upon both sides. The first of these is usually visible in health (but not always, especially in fat people), coursing obliquely over the sterno-cleido-mastoid muscle. When the head is turned toward the opposite side it usually swells still more. With the increased fulness it becomes distinct, perhaps can be felt. With nor- mal fulness the internal jugular cannot be made out, situated, as it is, under the sterno-cleido-mastoid muscle, where it is divided into the 1 See under Enlargement of Liver, of Spleen, also Ascites and the so-called Urine of Engorgement. 224 SPECIAL DIAGNOSIS. clavicular and sternal portion, just in the angle between these, at the bottom of the intersterno-cleido-mastoid fossa. Where it passes into the bulbus jugularis it has a valve (ordinarily exactly at the upper border of the sterno-clavicular articulation, but sometimes, especially in consequence of the engorgement, located somewhat higher). Ab- normal fulness of the jugular vein fills up the intersterno-cleido- mastoid fossa or it may cause a projection there. Dorsal posture increases the fulness. Fulness of the cutaneous veins of the trunk and extremities, not occurring without general engorgement, is usually not so pronounced as that of the veins of the neck, especially on account of the marked edema which accompanies the congestion. Important associated symptoms of general engorgement are cyanosis, edema, effusion into the cavities of the body, enlargement of liver and spleen, disturbance of the bowels, and so-called urine of engorgement} This condition arises when the right heart is not able to propel the required quantity of blood into the lungs. It occurs in various dis- eases of the heart, in emphysema of the lungs, and in all the conditions that lead to marked interference with the action of the heart, especially pericarditis. The most marked engorgement occurs in general when the right side of the heart is paralyzed after it has been obliged for a long time previously to meet unusual demands, and hence has become hypertrophied; hence with mitral and, more rarely, pulmonarydefectsand emphysema,and likewise in the very rare tricuspidstenosis andinsufficiency? General abnormal fulness of the veins may also be the result, exceptionally, of diminished flow of blood from the two cavae into the right auricle in consequence of pressure by a mediastinal tumor. Local increased fulness of the veins may be caused by a consider- able narrowing or closure anywhere of a venous trunk by a thrombus or by compression. The larger the vessel thus affected, the more extensive the area of abnormal fulness. Thus, sometimes abnormal fulness of the jugular and its branches, also of the ophthalmic vein (recognized by the ophthalmoscope), will be caused by a mediastinal tumor which presses upon the cava. Also the superficial veins of the skull between the ear and the fontanelle will become distended and tortuous if the longitudinal sinus of the dura is stopped. Fulness of the veins of an arm points to compression of the axillary vein (gener- ally tumors or scars from operations in the axilla). The swelling of the veins of the skin over or on either side of the sternum is a very important early sign of mediastinal tumor. The cutaneous veins of the leg are enlarged when there is thrombosis or compression of the femoral vein of that side. The veins of both legs may swell as the result of double thrombosis or compression of the vena cava inferior or both iliac veins (ascites, tumors). In all these cases there may be local edema.3 This may even give a better and earlier sign of local engorgement, but, on the other hand, it may conceal the fulness of the veins. In the majority of such cases the cutaneous veins supply the neces- sary collateral circulation. But this is especially the case in engorge- ment of the portal vein,4 whether due to cirrhosis of the liver or com- 1 See this. 2 See under 3, p. 229. 3 See this. * See also Enlargement of the Spleen, and Ascites. EXAMINATION OF THE CIRCULATORY APPARATUS. 225 pression or thrombosis of the portal trunk. Here we may see the abdominal veins enlarged, part of which go upward to the thorax and part downward to the inguinal region. In individual cases there is a crown of such veins around the navel—"caput Medusa"—since the umbilical vein, remaining open, receives a part of the overflow of blood which the portal is not able to carry. The fine dendritic vein-nets which are frequently seen on the lower portion of the chest, and here and there also on the back along the course of the lower boundary of the lungs, more rarely along the sternum or in the fossae supraspinatae, are difficult to interpret. They appear most frequently in emphysema of the lungs, and also in adhe- sive pleuritis. I have lately found them three times within a short period in cases of adhesive pericarditis on the boundary between the heart and lungs. Probably they are always signs of collateral circula- tion, which in pleural coalescence it is certainly not difficult to under- stand, but more difficult in emphysema. However, such vein-nets are sometimes also seen in persons in whom no anomaly of the thoracic organs can be found. Very extensive enlargement and tortuosity of a large part of the cutaneous veins of the trunk or of the chest (generally symmetrical), or enlargement of single cutaneous veins of an extremity, also occur without any possible assignable cause (perhaps closure of a deep branch), so that, according to the views of the present day, it is to be regarded as an independent primary alteration of the respective veins. Whether this alteration is to be considered as a congenital disposition or an anomally gradually acquired later, possibly a kind of chronic phlebitis, cannot yet be decided. 2. Phenomena of Circulation in the Jugular Veins.—Respi- ratory Motions.—The suction action of the chest with inspiration causes a rapid emptying of the blood from the veins of the body into the heart during inspiration, as well as during expiration. On the other hand, a forced expiration, likewise strong effort, and very espe- cially the increased internal pressure within the chest which takes place in coughing before each cough-impulse, check the discharge. The alteration in the fulness of the veins in the neighborhood of the heart which is thus caused is usually only to be observed in the jugular veins. But in normal fulness of these veins the simple respiratory oscillation of their volume is not noticeable. Such veins only distinctly swell with marked pressing and coughing (whooping-cough), and then the veins of the face become very full. Yet when the veins of the neck are constantly abnormally full or engorged, then in ordinary breathing they show a corresponding to-and-fro swelling, and with forced expira- tion, pressing, or coughing they stand out very distinctly. The bulbus jugularis may then appear as a round bunch between the heads of the two sterno-cleido-mastoidei muscles; but even the whole internal jugular may swell and contract if the valve over the bulb does not close. This phenomenon occurs in the most marked degree with the labored expiration of emphysema. Here, also, in very rare cases, this variation in the fulness extends to the cutaneous veins of the face, the chest, and arms. The opposite condition of the veins of the neck, becoming tumid 15 226 SPECIAL DIAGNOSIS. with inspiration and emptying with expiration, may be caused by fibroid mediastinitis (mediastino-pericarditis). The cause of the phe- nomenon, like that of pulsus paradoxus} is the traction and bending of the large vessels during inspiration (Kussmaul). Venous Pulse.—Circulatory movements in the veins of the neck, which directly or indirectly depend upon the action of the heart, and hence are rhythmic, are designated as venous pulse. This motion may be communicated to or really be in the vessels (autochthonous, real pulse). The former is only the pulsation in the carotid communicated to the internal jugular, which shows most frequently and plainly when the carotid pulsates very strongly or when the internal jugular is very full, or if both conditions exist.2 We divide the real venous pulse, pulsation in the veins of the neck, into that which occurs in health, the so-called " normal" or negative, and the positive, which is always pathological. The normal venous pulse is presystolic, and usually is only observed in the external jugular. It would be best designated as a collapse of the vein accompanying the systole of the heart; for the external jugular, in exact correspondence with the apex-beat and the carotid pulse, quickly empties itself, and Fig. 80.—Normal venous pulse or venous collapse with systole of the heart, and (broken line) carotid pulse (after Riegel). immediately again slowly fills, sometimes visibly in two intervals, so that it attains its complete distention before the next systole of the heart, and hence is presystolic. This phenomenon depends upon the part the auricle plays in the action of the heart: during the ventricular systole it is in diastole, and thus favors the flow of blood from the veins. Shortly after the begin- ning of the ventricular diastole it begins to contract, and thus the flow of the venous blood from the cava into the auricle is impeded. It seems to me that the first elevation of the ascending side of the tracing of the curve of the venous pulse has not yet been explained. In health this pulse is seen to a very small, scarcely noticeable, degree; it is beautifully seen in dogs when the jugular is laid bare. In healthy per- sons, without any known reason, it is in some cases strong enough to be observed. But sometimes it is still stronger when the external jugular is abnormally full, hence in engorgement. Often this pulse occurs only indistinctly; its rhythm is difficult to recognize, and it is also affected by the pulsations of the carotid. Then we speak of undulation in the veins of the neck. 1 See this. 2 For distinction between this and genuine systolic venous pulse, see p. 227. EXAMINATION OF THE CIRCULATORY APPARATUS. 227 The positive venous pulse is systolic, hence is contemporaneous with the carotid pulse. It is a pathognomonic sign of insufficiency of the tricuspid valve, and is caused by the contraction of the right ven- tricle, which causes a regurgitant positive blood-wave into the cava and its nearest branches through the imperfectly closed right ostium vcnosum. It first and most markedly appears in the internal jugulars or their bulb, and generally only here. The very direct course of the innominate and right jugular from the cava causes the right jugular vein to show the phenomenon more frequently and stronger than the left. If the valve of the vein closes above the bulb of the jugular, then^ the regurgitant wave ends there. This pushes the bulb up and distends Fig. 81.—Positive jugular pulse compared with (C) carotid pulse (after Riegel). it, and it is then seen, enlarged and pulsating, in the intersterno-cleido- mastoid fossa (bulbar pulse). The bound of the pulse-wave against the valve sometimes causes a valvular sound in the. jugular. But ordinarily the valve is insufficient from previous engorgement (or is congenitally so), or it becomes so from the distending action of the pulse, and then the pulse-wave passes into the internal jugular, and exceptionally also into its branches in the face. This systolic pulse must likewise be supposed to be propagated to a certain extent also in all other veins that are directly given off from the cava; but they cannot be examined except in a large venous territory—the veins of 228 SPECIAL DIAGNOSIS. the liver. Here the pulse manifests itself by a constant systolic swelling and diastolic collapse of the organ—the venous liver-pulse. Palpation of a liver thus constantly enlarged frequently shows the phenomenon of systolic venous pulse to a high degree. The systolic jugular pulse may be graphically represented, as is shown in Fig. 81. The mode of procedure in palpating the liver-pulse is as follows : One hand is placed upon the right hypochondrium or the epigastrium ; the other is passed around the chest at the level of the eleventh and twelfth ribs posteriorly. We can then feel that the organ is systol- ically enlarged, and thus we may avoid confounding it with lifting up of the liver by the aorta or even with marked epigastric pulsation. Moreover, we recognize the liver-pulse in this way easier—that is, sooner—than by simply palpating in front. The liver is usually enlarged, almost always by the previously existing engorgement;1 at least, it immediately becomes so if tricuspid insufficiency occurs, as we very distinctly observed in a case of mitral insufficiency and stenosis, in which relative tricuspid insufficiency occurred, then subsided, and again reappeared. Arterial liver-pulse is exactly like venous liver-pulse in its phenomena (in aortic insufficiency).2 For the production of a recognizable venous liver-pulse, as well as a strong jugular pulse, there is, of course, required a certain moderate (and, if it has not been met with before, also it must not be too fre- quent) action of the heart. As the heart grows more and more weak the liver-pulse fails, and the jugular pulse gradually becomes smaller and more slow, until finally there is only a slight to-and-fro movement of the vein. In order to make a differential diagnosis of the different kinds of pulse in the veins of the neck it is necessary to bear in mind the fol- lowing: i. The transmitted pulse will be best distinguished from the positive real pulsation occurring at the same time with it by placing the finger or, better still, a pleximeter, with its edge in the middle of the neck, upon the vein : if the pulsation is communicated, it disap- pears in the central empty portion and becomes more distinct in the periphery from the engorgement of the distended portion; on the other hand, a positive genuine pulse remains centrally unchanged. 2. The negative true pulse is distinguished from the positive and from the communicated pulsation generally by comparison with the apex-beat, as well as by comparison with the carotid pulse. (We seize the left carotid and at the same time observe the right jugular.) It is also to be observed that with the negative pulse the collapse of the vein is usually quick, and that it refills slowly. In this way, with a little practice, one can often immediately judge correctly. In order more exactly to observe and study these phenomena it is well to have the patient for a time breathe very superficially, or, if pos- sible, to hold the breath, so as to eliminate the respiratory to-and-fro swelling of the veins. We must still mention some occurrences that are extremely rare or are of very little diagnostic value: 1 See Enlargement of the Liver. i See p. 221. EXAMINATION OF THE CIRCULATORY APPARATUS. 229 Diastolic collapse of the cervical veins (Friedreich), which looks very like systolic venous pulse, sometimes occurs in adhesive pericar- ditis and fibroid mediastinitis, and is connected with systolic drawing- in in the neighborhood of the heart, which occurs with this condition.1 The springing forward of the heart in the diastole, together with the forward movement of the anterior wall of the chest, probably produces an aspiration of the contents of the large veins. Systolic venous pulse may exceptionally occur with mitral insuf- ficiency and open foramen ovale: through the latter and the left ostium venosum the contraction of the left ventricle produces a recur- rent pulse-wave in the cavae and their nearest branches (very rare, being thus far only observed in one case). Double positive venous pulse (Leyden) is observed in hemisystole. 3. Phenomena of Circulation in Other Veins.—Systolic true pulse may, as has already been mentioned, be propagated to the veins of the face, but this is rare. In individual cases it has even been ob- served in the cutaneous veins of the arm, in the small branches of the internal mammary (of which I have seen one case), in the vena cava inferior (Geigel), etc. The so-called progressive or ascending venous pulse (Quincke, Holz) has been seen in the veins of the hand and the back of the foot and in those of the forearm up to the elbow. This phenomenon may be met with in very different conditions: it seems to appear principally when the vessels of the extremities have a diminished tonus, the veins more or less full, and when the heart acts vigorously. Quincke has observed the ascending venous pulse in febrile states of every kind, in cerebral and spinal diseases, in chlorosis and anemia, finally in healthy subjects during hot weather. Holz and Senator have seen it in pseudo- leukemia and leukemia. Probably it can scarcely be explained otherwise than as an arterial pulse propagated through the capillaries; but opinions still differ about the real conditions of its occurrence, and also as to its prognostic sig- nificance. As is evident from what has been said, as yet it cannot be turned to account diagnostically. 4. Venous Thrombosis.—The transformation of the soft venous tubes into firm round cords that can be felt exhibits venous thrombosis. The thrombosed vein may often also be perceived by pressure. In internal medicine, of especial interest and importance is thrombosis of the large veins of the lower extremities as it sometimes occurs in the course of severe acute infectious diseases as the result of chronic in- validism, and in marasmus of the aged. Frequently, but never while resting in bed, it occurs in the edema of engorgement in the affected limb. It is important to touch such veins very carefully in order not to push off a piece of the thrombus. A piece torn off from the central end of the thrombus may be carried to the right ventricle, and from thence produce an embolism of the pulmonary artery. 1 See pp. 176, 177. 230 SPECIAL DIAGNOSIS. Auscultation of Veins. I. Sounds and murmurs of short duration are sometimes heard over the jugular and crural veins. In tricuspid insufficiency there is a systolic recurrent blood-wave, which, by its impulse against the closing valve above the bulbus jugu- laris and against those in the crural vein at Poupart's ligament, and also by the sudden tension of the vein itself, causes a sound which will be heard by very lightly placing the stethoscope at these points. But a sound has also been heard where the crural valve was defective. In such cases it must be alone caused by the sudden tension of the venous tube. If these valves are insufficient, there may be a corresponding short murmur (very rare). The jugular sound generally accompanies the bulbar pulse of tri- cuspid insufficiency. A venous sound over the crural is, however, rare, because the recurrent wave only exceptionally reaches this vessel. Quite exceptionally with tricuspid insufficiency there may be a double sound over the crural vein, indicating first auricular, then ventricular, contraction (Friedreich). It can be distinguished with certainty from the sounds, double sounds, and murmurs of the crural artery only when there exist signs of aortic or tricuspid insufficiency (hence, how small is the diagnostic value of these phenomena!). Crural, arterial, and venous sounds may be combined when there exists at the same time aortic and tricuspid insufficiency. Now and then, even in health, especially in thin persons, a sound is produced over the crural vein by sudden straining or coughing (expira- tory valvular sound in the crural vein—Friedreich). 2. A continuous murmur, designated as venous humming, venous murmur, or buzzing, is often heard in anemic, and especially in chlo- rotic, patients, but sometimes also in many healthy persons, over the jugular veins. It is usually louder on the right side. It sounds like a regular humming or a very fine whizzing, or like the humming of a top. If it is very marked, it can also be felt. The murmur is caused by the whirl in the blood as it flows from the narrow jugular into its wider bulb. The whirls are the more marked the more rapid the stream, and hence the murmur becomes louder in deep inspiration ; and for the same reason it is generally louder in the upright position than when lying down. And likewise it is not infrequently louder in the diastole than in the systole of the heart. Also, the predominance of the right jugular over the left is explained by the difference in the rapidity of the current caused by the different shape of opening into the cava.1 This murmur will be increased by slight compression, as may be produced by the stethoscope or by turning the head to the opposite side. This latter effect comes from the tension of the fascia colli, and probably also from the contraction of the omo-hyoideus muscle. As to what the occurrence of this murmur means, we must rest upon the old idea that it chiefly occurs with anemic, and especially chlorotic, patients. Friedreich's claim that it is more marked in these cases, while in health it is usually only to be heard as a soft humming, seems to me 1 See above, p. 227. EXAMINATION OF THE CIRCULATORY APPARATUS. 231 to be very far fetched. Strictly speaking, no diagnostic importance is to be attached to this phenomenon. A similar murmur occurs exceptionally in other veins, and it is to be noted almost exclusively in anemia; thus, in the large veins of the extremities and also in the intrathoracic trunks. Here the murmur is always much stronger during the heart's diastole, and can thus appear to be interrupted. It has already been mentioned that Sahli declared the anemic heart-murmurs to be in part propagated from the venous trunks in the chest. EXAMINATION OF THE BLOOD. Preliminary Remarks.—We can only approximately determine the total amoutit of blood in a healthy person. Its direct determination is of course impossible, and we are compelled to form approximate conclusions from animals. In mammals the quantity of the blood fluctuates considerably: it is between one-eleventh and one-twenty- third of the weight of the body. In dogs the variation is from one- eleventh to one-eighteenth of the weight. Of the quantity of the blood in diseased conditions we know from autopsies scarcely more than that it is diminished in a very conspicuous manner after severe hemorrhages and after the loss of large amounts of the water of the organism, as in cholera Asiatica and other severe diarrheas. But at the bedside we are still less able to estimate the quantity of the blood of the patient, even approximately. We certainly know that in genuine anemia from hemorrhage the color of the skin and of the mucous membranes becomes paler and the pulse smaller; but only under quite exceptional circumstances can we reason backward, vice versa, from these signs to a diminution of the quantity of the blood, because paleness and weak- ness of the pulse may also be produced by disturbances of the circula- tion, and because paleness may be caused by a watery quality of the blood in itself—i. e. hydremia without anemia. Thus we know almost nothing of the quantity of the blood of the patient, and the conception " anemia " has a very defective foundation. Apart from particular cases mentioned above, perhaps upon the whole it never exactly applies, because it has been proved experimentally that the blood in a high degree has the capability to balance a diminution of its quantity by quickly absorbing water. Nevertheless, if the expres- sion "anemia" is used, it is only because it has become naturalized. According to our present views it corresponds with the conceptions of hydremia, hypalbuminosis, diminished hemoglobin on the one hand, and diminution of the red cells on the other. It must be pointed out that the last-named state need not go quite parallel with the first- named. In respect to the so-called anemias, it is therefore of interest for the diagnostician to know in the first place the percentage of water and albumin, and particularly the percentage of hemoglobin—i. e. coloring-matter of the blood—and the number of red and white blood- cells. Besides, there are conditions in which the spectroscopical behavior of the blood is altered—conditions in which the form, size, and structure of the red and white cells are altered. There are also pathological admix- 232 SPECIAL DIAGNOSIS. tures of different sorts, and finally certain less important chemical altera- tions, as, for instance, decreased alkalescence, etc. The examination of the blood must therefore include a number of points of view, but they do not all of them always come into consid- eration. Frequently we may be content with a very simple procedure, according to the result of which, and according to the remaining factors of the patient's condition, further investigations must be made. Anticipating somewhat, we here give a synopsis of the different steps in making examinations of the blood: i. The most simple procedure, which is often sufficient, and where it is not sufficient gives hints as to further examinations, is: determina- tion of the percentage of hemoglobin (Gowers-Sahli's hemoglobinometer) and inspection of a fresh microscopical preparation. 2. A procedure which is sufficient for most pathological conditions of the blood: besides determining the amount of hemoglobin and the inspection of the fresh microscopical specimen, we are to count the red and white blood-cells and determine their proportion to each other. We are also to make and inspect an eosin-hemotoxylin preparation. To these there follow in succession : (a) either exhibition of Ehrlich's granulations and of the nuclear structure of the leucocytes; (b) or, as may be necessary, other special methods, as, for instance, a study of the micro-organisms. Sometimes from the beginning we have only to examine for micro- organisms (recurrens [spirillum of relapsing fever], anthrax, etc.); sometimes the attention is principally directed to the spectroscopic quality of the blood (certain cases of poisoning), etc. These details will become clear from what follows. Regarding the value of centrifuging the blood by means of the hematocrit we have no basis for a personal opinion, though we doubt whether the method will have a lasting value for the diagnostician. The methods of obtaining blood differ according to whether a smaller or larger quantity is desired. For most purposes it is suf- ficient to obtain the blood by a puncture in the tip of the finger or lobe of the ear. After having used it for many years, we can most strongly recommend the scarificator devised by Francke (made by Katsch in Munich), and we particularly emphasize these points in regard to it: it can be easily disinfected; it can be used for the smallest punctures; it can be so arranged that only the fine point of the lancet pene- trates the skin. A particular advantage we found in the fact that, instead of using the finger-tip or lobe of the ear, we may use a place a very little larger, and may obtain the drop of blood at a place less rich in blood-vessels, as somewhere on the arm. This is in every respect a better place. If a larger quantity of blood is required, as is desirable in making cultures and is indispensable for quantitative chemical analy- sis, we recommend the very simple and perfectly safe method which v. Ziemssen has recommended, which consists in removing the blood by aspirating the median vein.1 i. Color (Amount of Hemoglobin); Spectroscopic Character of the Blood ; Density of the Blood.—Blood taken directly from a healthy person is of a recognized color : if arterial, it is brighter, rich in 1 See p. 251. EXAMINATION OF THE CIRCULATORY APPARATUS. 233 oxygen—that is, rich in oxyhemoglobin ; if venous, it is darker, bluish- red—that is, it is poor in oxygen. The marked deficiency of oxygen in the blood of a person suffering from dyspnea or venous engorgement, or both, makes the blood very dark. In carbonic-acid poisoning the blood is bright cherry-red; from chlorate of potash, anilin; and in severe poisoning by hydrocyanic acid and nitrobenzol it is brownish- red or chocolate color. In severe anemia and chlorosis (hydremia) the blood is watery; in marked leukemia it looks a peculiar whitish-red, as if mixed with milk, or chocolate color. These changes in the color of the blood all have an effect upon the color of the patient's skin, as has already partly been mentioned. Hence patients with carbonic-acid poisoning look strikingly rosy, while in poisoning with chlorate of potash, anilin, and nitrobenzol the skin and mucous membrane are a peculiar grayish-blue or black color. These discolorations of the skin, as well as the differences in the color of a drop of blood obtained by pricking with a needle, have too little distinction to be directly of diagnostic use. But, especially with regard to the poisons that have been mentioned, if they are recognized as unusual, they demand that a timely and thorough examination of the blood be made by the spectroscope or microscope. In this lies the great value of a knowledge of these discolorations. For recognizing hemoglobinemia (from the hemoglobin that appears in solution in the serum of the blood originating from the red blood- corpuscles) it is necessary to employ a wet cupping-glass, or to take blood from a vein after the method of v. Ziemssen. The blood thus withdrawn is allowed to stand covered for twenty-four hours, if pos- sible in an ice-chest, and then the serum, separated from the coagu- lum, is to be examined. That from normal blood is yellow, in hemo- globinemia it is rubine-red, and in the spectroscope gives the bands of oxyhemoglobin.1 Approximative Determination of the Amount of Hemoglobin.—A dim- inution in the amount of the hemoglobin may be conditioned upon a diminished number of red corpuscles or upon a decrease in the amount in single corpuscles, or upon both.2 The color of the skin is a very unsafe index of the percentage of hemoglobin in the blood. The color of the mucosae also is often misleading, but in any case is always a very inexact index, for reasons we have already pointed out. There- fore, lately reliance is more and more placed on the examination of the blood itself. In extreme anemia the drop of blood which exudes from a wound made by a needle-puncture on the finger appears distinctly pale to the practised eye, and enables it to recognize without doubt a diminished percentage of hemoglobin. To make possible, however, the judging by the eye of the percentage of hemoglobin in a drop of blood, even in slighter variations from the normal, technical aids are absolutely necessary. Of late there have been constructed to this end a number of instruments. We mention here only two, which we most strongly recommend; Fleischl's hemometer and Gowers's hemoglobin- ometer. Both of them possess by no means absolute exactness, but are sufficiently accurate for the purposes of practice, and are comparatively simple and quick in giving results. Formerly we always used only 1 See below, p. 236. 2 See below. 234 SPECIAL DIAGNOSIS. Fleischl's instrument, but lately, in consequence of the earnest recom- mendation of Sahli, we have frequently used also the much cheaper and still more simple instrument of Gowers. We recommend the latter instrument to every practitioner for widest use in diagnosis of anemia and determining its degree. The principle of the hemometer of Fleischl is as follows : A certain very small quantity of blood (obtained by a prick of a fine lancet, or, better, by means of a [Francke] scarificator), is thinned by a definite quantity of water, and then by lamp or gaslight the color of this mixture is compared with the color of a glass wedge which has been colored with Cassius's gold purple and carries a movable scale. Upon this scale the figure ioo corresponds with the intensity of color of a mixture of normal blood. Material that has less inten- sity has the numbers 90, 80, etc., down to 10, thus giving directly the percentage relation of the mixture of blood that is being exam- ined to that of normal blood with reference to the quantity of hemo- globin. Thus, 50 indicates, if the mixture of blood has been properly prepared and corresponds in color with the color of the glass wedge at that point of the scale, that this blood contains only 50 per cent. of the normal quantity of hemoglobin. This instrument gives inexact results, varying in extent with dif- ferent specimens, but, except when the amount of hemoglobin is greatly diminished, the inexactness is not sufficiently marked to vitiate the conclusions. Dehio gives the following table of variations with his instrument. (The findings were too small by the amounts represented by the figures in the second column.) With 90 per cent, of hemoglobin............0.4 With 70 " " ............2.8 With 50 " " ............4.5 With 20 " " ............5.5 The principle of Gowers's instrument is similar: it is to determine how much a certain very small quantity of blood must be diluted to have the mixture agree in intensity of color with a normal solution, which consists of picric acid and carmin in glycerin. This solution, however, can be used only for comparison in daylight. For use in artificial light Sahli has made another solution which he calls " normal solution to Gowers's hemoglobinometer." (It is sold by the optician Hotz in Berne.) Water is used as the diluent for the blood. Method of Using Gowers's Hemoglobinometer.—A small wooden block forms a stand for the tubes b and c (see Fig. 82). The tube b is closed and contains the test liquid, picric-acid-carmin solution. The tube c is open at the top and serves for the reception of the blood-mix- ture which is to be examined. On this tube is a scale which gives the percentage of hemoglobin in the blood which is being examined, compared with the percentage of hemoglobin in normal blood. Into the little tube c are put a few drops of water to immediately dissolve the blood as it is poured into it. Then a puncture is made with Katsch's scarificator according to the method given above, and, as the blood exudes, by means of the sucking pipette it is slowly sucked up to a mark on this pipette. The point of the pipette is now to be EXAMINATION OF THE CIRCULATORY APPARATUS. 235 d n Fig. 82.—Gowers's hemoglobin- ometer (after Rieder). quickly wiped, and then its contents squirted directly into the water which is at the bottom of the tube c. Several times the pipette is to be refilled with water and emptied into the tube c, in order not to lose any blood on its capillary wall. The pipette itself may be used for stirring the mixture in the tube c if care is taken to completely empty it so as not to lose anything adhering to it. Water is now slowly added to the tube c, by means of the pipette, till its contents correspond in color exactly with the color solution in the tube b. It is best to hold the tubes against a white surface. When the two tubes have been made to correspond exactly in color, the number up to which c is filled is read off. The number 100 rep- resents the normal percentage of hemo- globin in the human blood. If the liquid stands at 40, for instance, it means that the percentage of hemoglobin in the examined blood is in proportion of 40 to 100 to that of the normal blood; that is, the examined blood contains only 40 per cent, of the normal quan- tity of hemoglobin. From this can be calculated the absolute percentage of hemoglobin in the specimen of blood by putting at 14 per cent, the percentage of hemoglobin in normal blood. The examined blood contains, then, in 40 X 14 , r , ... 100 grams -----—— = 5.0 g. of hemoglobin. The average limit of error of this instrument is very small: Rieder gives it as 3 per cent. Since its contents become pale with the lapse of time, the test-tube b must be renewed from time to time, or it must be controlled by a solution of normal blood which has been diluted to 100. This is not the place to speak of the more exact methods of determining the percentage of hemoglobin. We refer to works upon physiology. Spectroscopic Character of the Blood.—In certain cases its examina- tion has decided significance. Recently it has been rendered very much more easy by very practical clinical and uncomplicated apparatus, of which we may mention the spectroscope devised by Desaga (Heidel- berg), and still more recently Hering's very cheap spectroscope without lenses. The latter, after a little practice, is entirely satisfactory for clinical purposes. The blood or the blood-serum, having been diluted with water, is held in a test-tube before the slit of the instrument and examined against a white light. In three classes of cases the spectroscopic examination of the blood gives a valuable result; in hemoglobinemia there is no doubt about the presence of the coloring-matter of the blood in the serumx if the serum shows the absorption-band of oxyhemoglobin; one in yellow near green (close to D, Frauenhofer), and one in green near the former, between D and E. Moreover, in carbonic-oxid poisoning there appear 1 See p. 232. 236 SPECIAL DIAGNOSIS. in the blood two absorption-bands which are very near the two above mentioned, only a little nearer the violet line, and hence they may be confounded with them, but they are very distinctly separated from bands of oxyhemoglobin in that they do not disappear on the addition of ammonium sulphate (since carbonic oxyhemoglobin is not thus reduced). Lastly, it has recently been discovered that in poisoning with chlo- rate of potash, methemoglobin occurs in the blood in the living organ- ism. In acid and neutral solutions this causes an absorption-band in yellow (between C and D), besides three others more faint, which coin- cide with that of hematin, but which are distinguished from it in that /• 2, 5. V. 5. FIG. 83.—Spectrum absorption-bands of the coloring-matter of the blood and its derivatives (after Rieder). upon the addition of ammonium sulphate it first gives place to the absorption-bands of oxyhemoglobin, then to that of O-free hemoglobin (a broader band from D almost to E in green and yellow). In alkaline solution methemoglobin shows a narrow band in yellow near to D, and one in yellow-green and green. There are still other changes in the blood, partly relating to its color and partly relating to its behavior in the spectrum, when animals are poisoned, but they do not seem to require special mention in this book. Determination of the Consistence of the Blood, or its Specific Gravity.— In recent years different methods have been devised by v. Jaksch, Hammerschlag, and Schmaltz. We must abstain from a criticism of them, as we have not made any comparative investigations with them. But we can say of them all that they are superfluous for diagnostic purposes, since Schmaltz found that the specific gravity of the blood is almost exclusively determined by the percentage of hemoglobin ; at all events, it goes parallel with it. The determination of the density of the blood can, therefore, be replaced for clinical purposes by the much more simple and comparatively more exact determination of the hemo- globin. 24034�37 7337 4137 EXAMINATION OF THE CIRCULATORY APPARATUS. 2. Microscopic Examination of the Blood.—The normally formed constituents of the blood are, as is well known, the red and white blood-corpuscles and blood-plates. The morbid conditions of the blood which can be recognized by the microscope may be divided as follows: Alterations in the number of the red and of ivhite corpuscles, or varia- tions in the numerical proportion of these two components of the blood. Abnormal size, and form, and peculiarities of the structure of the red cells. Abnormal quality of the white cells. Admixtures: These, in the first place, are products of decompo- sition from the blood itself, and micro-organisms. About some of these points the fresh, unstained preparation gives explanation; others, and especially the quality of the white cells and most of the micro-organisms, can only be recognized in stained dry preparations. Mode of Procedure.—For the purpose of making a fresh, unstained blood-preparation there are required object-glasses and cover-glasses, cleaned as thoroughly as possible. If they are cold, they must be warmed a little. Then the place of puncturel must be washed with water or a fresh | per cent, solution of table salt, and then wiped dry. A puncture is made with a clean needle or with the extreme point of Francke's scarificator.2 The blood which first escapes is to be wiped off, and that which flows afterward is removed with a cover-glass, which is to be immediately dropped upon the object-glass held in readiness, or a drop is received on the object-glass and covered quickly with the cover-glass without any pressure. It is not advisable to promote the flow of blood by pressure on the parts surrounding the place of puncture. The examination must be made at once, because the red blood-corpuscles, as well as the white, after a short time are subject to alterations. Spots at the edge of the preparation or in the neighbor- hood of air-bubbles are not to be studied, because here the red cells shrink and decompose. For the purpose of demonstration the prep- aration can be preserved for a brief time by encircling it with oil. Counting the Blood-cells.—When one wishes to count the red and white cells a somewhat larger puncture is required. Francke's scari- ficator, with its lancet arranged so that it comes out one-half its length, is particularly useful here, but in this way a sufficient drop of blood can be gotten from the arm or the ball of the little finger. Making Dry Preparations.—For this purpose only fine punctures are needed, also very thin, somewhat larger, new cover-glasses, which immediately before being used are to be cleansed with water, alcohol, and ether, and well dried. Take one of them between the thumb and forefinger of each hand; take up with the edge of one some freshly upwelling blood and spread it over the other in the finest possible layer, or pass the other quickly across the spot of the first, which is moistened by the blood. Microscopical Examination for Micro-organisms.—For this purpose a particularly careful cleansing of the place of puncture and of the 1 See above. 2 See p. 232. 238 SPECIAL DIAGNOSIS. glasses is necessary. Strict antisepsis and asepsis is, however, of course, only necessary if the blood is to be used for making cultures. 1. Alterations in the Number and Appearance of the Red Blood- corpuscles.—These are ascertained on the fresh, unstained prepara- tions. A counting-apparatus is required for counting them. The one by far most to be recommended is that of Thoma-Zeiss.1 A cubic millimeter of blood from a man normally contains about 5,000,000 red blood-corpuscles; from a woman there are 4,500,000 (C. Vierordt, Laache). A morbid diminution observed in a single examination of a case could only be positively asserted if the enumera- tion showed one-half of this number or less. The smallest quantity found in disease is about 400,000 to the cubic millimeter. Oligocythemia is a diminution of the red cells if the whole quantity of blood is taken as the unit of measure. This is the alteration of the blood which accompanies the different forms of anemia (hydremia), of pernicious anemia, and leukemia. Exactly parallel with this may be an alteration in the percentage of hemoglobin ; but a complete parallelism may also be absent here, for in pernicious anemia the number of blood-corpuscles is certainly diminished, but the percentage of hemo- globin is greater,2 and therefore the whole blood contains, it is true, little hemoglobin, but more than would be expected according to the existing oligocythemia. Conversely, in chlorosis the percentage of hemoglobin is much diminished, as has been mentioned before, but there is no, or very little, oligocythemia, because in this disease there exists essentially an impoverishment in respect to hemoglobin. Counting the Blood-corpuscles.—In anemia, in a stricter sense, it has a diagnostic value, but it has even greater value in that it enables one to recognize the course of an anemia—its improvement or deterioration —and this, after what has already been said in the introduction, forms its diagnostic value in a wider sense. But, as follows from what has been said above, since in chlorosis the number of the red cells has to be considered only a little, and since in common anemias there exists usually also during the course of the disease a certain parallelism between the number of blood-corpuscles and the percentage of hemo- globin, we may say that in chlorosis and simple anemias for determin- ing the course of the disease it is generally sufficient to control the percentage of hemoglobin, which requires less time and trouble than counting the cells. Method of Counting.—The Thoma-Zeiss apparatus for counting the number of corpuscles is the best of all those now in use.3 It consists of a mixer and a Hayem's counting-chamber. The mixer serves to distribute the blood in as equal a manner as possible—a very important point. For thinning the blood a 3 per cent. solution of salt is recommended. The mixer is a kind of measuring- pipette with a very fine canal and with a spherical enlargement con- taining a little glass ball. The portion of the tube below the cavity has the marks 0.5 and 1.0. Just above the cavity is the mark 101. The * See below. 2 See below. 3 Miescher has lately made some alterations in this apparatus which are calculated to increase the accuracy in counting. I have not yet had the opportunity to test the instrument in its new form. It is to be obtained of Karl Zeiss in Jena: Melangeur after Miescher. EXAMINATION OF THE CIRCULATORY APPARATUS. 239 first two marks are those to which the blood, directly after it has been drawn from the finger, is sucked. If we wish a mixture of 1 to 200, we draw it up to 0.5 ; if a mixture of 1 to 100, to 1.0. In both cases we wash off the blood clinging to the point and draw in a 3 per cent. solution of salt, or Hayem's fluid, to 101. Then the mixer is shaken several times, so that the glass ball equally mixes the contents. We next expel the contents of the fine tube, which consist of salt solution or Hayem's fluid, after which we fill from the mixture a Hayem's counting-chamber. This consists of an object-glass with a circular excavation; it is a space exactly -^ mm. deep, the floor of which is divided into microscopic squares whose sides are ■£$ mm. long. The cubic capacity of the space over each square is 2V x 2V * to c-mm- — 40V0 c-mm- Hayem's fluid is: hydrarg-bichlorid, 0.5; sodii sulphat, 5.0; sodii chlorid., 2.0; aquae destil., 200.0. Into this cavity some of the blood-mixture is blown, and then covered with a glass cover after carefully expelling any air-bubbles. After waiting a moment, in order that the blood-corpuscles as far as possible may equally distribute themselves, we magnify it about 50 diameters, and count the number of corpuscles in the larger number of the above-named squares, and thus obtain an average of the con- tents of, say, sixteen of them. The oftener these sixteen squares are counted the greater will be the accuracy of the result. We can calcu- late the number of corpuscles in a cubic millimeter from the proportions of the mixture and the cubic contents of the squares, as given above. Immediately after use the mixer must be most carefully washed with water, alcohol, and ether, and it is best to afterward dry it with the air-bellows. The proportion between the quantity of red cells and the percentage of hemoglobin in the blood is, however, by no means constant, because the percentage of hemoglobin in the individual blood-corpuscles varies in different morbid conditions. This is of diagnostic importance. Here are opposed to each other in a pronounced degree chlorosis and so-called idiopathic or pernicious anemia. In chlorosis there is a markedly diminished percentage of hemo- globin of the blood, with a slight, or at least proportionately slight, diminution in the number of red corpuscles. The individual cells are even poorer in hemoglobin, as occurs in chlorosis of a high degree in the ordinary fresh microscopic blood-preparation. Dehio has lately found a similar behavior of the blood also in phthisical and carcinom- atous cachexia and in the anemia of beginning secondary syphilis (formerly called syphilitic chlorosis), but the investigations of Sadler contradict this. On the contrary, in pernicious anemia the percentage of hemoglobin is less diminished ; the number of red cells, and particularly their whole volume, are more diminished. For this reason the remaining cells are extremely rich in hemoglobin. On the other hand, Dehio found closely similar to this form the anemia caused by the bothriocephalus latus,1 which also otherwise shows similarities to pernicious anemia or may even change into it. 1 See below. 240 SPECIAL DIAGNOSIS. 2. Alterations in the Size and Form of the Red Corpuscles.1— Red cells reduced in size, enlarged, and abnormally shaped may be observed—microcytes, macrocytcs, poikilocytes. On all the cells absence of the depression is noticed. These changes, combined with a decrease in the number of the red corpuscles, and at the same time a normal condition of the white cor- puscles, constitute the condition of the blood of so-called pernicious anemia. However, it must here be remarked that lately this is not regarded as a simple disease in itself, since we have learned to recog- nize it in many cases as a secondary state following different influences very injurious to the body. We shall return to this subject again a little later on. The simplest way of determining the size is to compare a prepa- ration of blood with that of a healthy person (the examiner himself). The normal diameter of red blood-corpuscles is y.y to 8// \i. c. about Ww of an inchJ- Microcythemia.—By this we understand the occurrence of forms containing hemoglobin, which are smaller than red blood-corpuscles, in which the form is nearly or quite perfect, or, if they are very small, they are simply globular, and then are always very rich in hemoglobin. We see the former in the new formations of blood after hemorrhages and also in all kinds of anemia. They are probably young red cor- puscles. The latter—microcytes, strictly so called—occur especially frequently in genuine pernicious anemia, and also in all severe second- ary forms of anemia. The supposition that they are sometimes formed upon the glass slide is possibly correct, because they may even be found in normal blood if the preparation contains air or if it has been pressed, or also if it has not been freshly made. I have never seen them when examining a perfectly fresh, otherwise normal, preparation of blood, except at the border (the effect of air). Macrocytes—abnormally large red corpuscles—besides those of normal size and very small ones—occur in individual cases of marked and simple anemia, but especially in pernicious anemia. This disease must always be suspected when they are present. Moreover, very often the poikilocytes to be described below are larger than normal [red corpuscles]. Nucleus-containing macrocytes (gigantoblasts—Ehrlich) seem to be the surest sign of a degradation of the blood-making organs and also of pernicious anemia. However, it is to be remembered that, accord- ing to our present knowledge, the alterations of the blood in pernicious anemia may occur secondarily to grave injuries of the organism. Poikilocytes, strictly speaking, are red corpuscles changed in form. They may assume the greatest variety of forms: club, biscuit, pear, flask, and drumstick are the most usual forms. In many ways poikilocytes correspond to enlarged red corpuscles. In individual cases they exhibit ameboid movements. In a wider sense we employ the expression poikilocytosis for a mixture of such forms with micro- cytes and macrocytes, which are almost always present. We must avoid confounding with them the mulberry and thorn- apple forms, which occur normally, or mechanical or chemical prod- 1 Compare Fig. 84, p. 241. EXAMINATION OF THE CIRCULATORY APPARATUS. 241 ucts, by using the greatest care in making the preparations and then immediately examining them. Poikilocytosis, strictly speaking, is not at all in itself a pathognomonic symptom of pernicious anemia, although in other forms of anemia it does not occur so regularly and in so marked a degree as in pernicious anemia. For a diagnosis of pernicious anemia there is necessary the presence of both macrocytes and gigantoblasts (see Fig. 84). As a Fig. 84.—Progressive pernicious anemia ; FIG. 85.—Primary anemia gravis; mag- magnified 300X. Dry preparation, eosin- nified 300X. Dry preparation, eosin-methyl- hemoglobin. The red blood-corpuscles all ene-blue. All the red cells have the umbilicus. without umbilicus. Macrocytes, microcytes, Macrocytes, microcytes, poikilocytes (from shadows, poikilocytes, two megaloblasts, two Rieder's Atlas). normoblasts, one lymphocyte (from Rieder's Atlas). distinction from pernicious anemia some call the severe anemia without the presence of megaloblasts "anemia gravis " (see Fig. 85). Pernicious anemia is, however, by no means always an independent disease. On the contrary, it has been observed in connection with tapeworm (espe- cially bothriocephalus latus), with severe leukorrhea, in carcinomatous cachexia, after exhausting hemorrhage from the stomach, and in pregnancy. As a matter of course, all these changes in the red corpuscles usually very notably accompany diminution in their number and of the amount of hemoglobin. Hence, as has already been mentioned, the amount of hemoglobin in single blood-corpuscles is not infrequently increased. (Regarding defects within the red corpuscles, which appear in acute infectious diseases and severe anemias, and may be mistaken for malarial parasites, compare under the latter.) In order to make visible the nuclei of the red blood-corpuscles a fixed dry preparation is stained with eosin-carbol-glycerin, and after- ward quickly stained with hematoxylin. The method is the same as that employed to bring out the eosinophile white cells. The bodies of the red blood-cells containing the nucleus often appear to have taken up the eosin remarkably strongly. 3. Normal and Pathological Condition of the White Blood- 16 242 SPECIAL DIAGNOSIS. cells.—The proportion of white corpuscles to the red in normal blood drawn by a puncture, according to the older examinations, was, on the average, from i to 400 up to 1 to 706. According to v. Limbeck, more exactly it is as I to 555 up to I to 625. That is, in a cubic millimeter of blood there are about 8000 to 9000 leukocytes. The white cells of normal blood exhibit different forms : (a) mononuclear, partly very small (i. e. approaching the red cells in size), cells with so- called basophil-granulation of the body ("lymphocytes"); (b) polynu- clear cells with polymorphic nuclei or with several separated, strongly tingeable nuclei, and finely granulated bodies with neutrophilous granu- lations ; (c) coarsely granulated cells with eosinophile granulations and weakly tingeable, often with multiple nuclei (" eosinophile cells "), the latter in very varying number; (d) now and then "mast-cells." An alteration in the proportion of the red and the white cells in favor of the latter indicates either leukocytosis or leukemia. In leukocytosis the increase of the white blood-cells is more or less temporary and slight in amount. All the forms of the white cells are increased or only the polynuclear neutrophile ones. The latter is particularly the case in the " inflammatory " and in the " cachectic " leukocytosis.1 Leukocytosis occurs physiologically during digestion. There is also a so-called " inflammatory " form in acute infectious diseases, particu- larly in those which are distinguished by the formation of large exuda- tions rich in cells, like pneumonia, but also in erysipelas, pleurisy, and peritonitis. In typhus abdominalis [typhoid fever], however, not only is there no leukocytosis, but, on the contrary, there is a diminution of the white cells. The name inflammatory leukocytosis may also be given to that form which is caused by the swelling of lymphatic glands in all kinds of local inflammation. Finally, there is to be mentioned the cachectic or hydremic leukocytosis occurring in all forms of anemia. This may be a relative leukocytosis, caused by diminution of the red blood-corpuscles, but also an absolute condition, as has been proved by enumeration of the cells. In the latter case it is probably to be explained by the acceleration of the lymph-current, which no doubt exists in consequence of the hydremia. According to the investigations of v. Jaksch, it appears at least as probable that the number of leukocytes has a prognostic value in pneu- monia : he found the inflammatory leukocytosis absent in severe, badly progressing cases. Leukemia is usually very easily microscopically distinguished from leukocytosis, because in this condition, in well-developed cases, there is a much more considerable increase of the white cells : most frequently there is approximately one white to ten red cells, but in the highest ' degree the proportion is about one to one. But in slighter degrees or at the beginning leukemia, especially the myelogenous and lienal-myelogenous forms, may be positively recog- nized on the basis of Ehrlich's observations. The early diagnosis of lymphatic leukemia, and particularly its distinction from leukocytosis, is certainly more difficult. In myelogenous and lienal-myelogenous leukemia there are found in 1 Compare Fig. 87, p. 243. EXAMINATION OF THE CIRCULATORY APPARATUS. 243 the blood: (a) one-sidedly increased eosinophile cells—the compara- tively least safe sign, because an increase of this formation occurs else- where, even in health, particularly in infancy: large eosinophile cells T£r<©c0i 0 °© ®l&> #^ '■A •v© ©, 3d. FIG. 86.—Normal blood. Magnified 300X. Dry preparation, eosin-hematoxylin. In the field of vision a lymphocyte, a poly- nuclear cell, and an eosinophile one. The nuclei of all the white cells dark blue, the eosinophile granulations a brilliant red (from Rieder's Atlas). •V $3^ FIG. 88.—Lienal-myelogic leukemia; magnified 3COX- Dry preparation, eosin- hematoxylin. Most of the white cells are uninuclear; many are strikingly large, with large plump nucleus. Several eosinophile cells. One nucleus contains red blood-cor- puscles (from Rieder's Atlas). 9J> ©° Tfc? 0&>0°0 r°o.% * <,o * 0° o o 8 0°O0 ,o o^ .00 ?«•**« ^

ff V" "'•■. ^■Left mammillary line. -RJL& -CD. FlG. 102.—Position of the abdominal contents. CA, sending colont; CD descending colon ;/?/-C, ileo-cecal region ; RJ, inguinal region ; RHs, left hypo- chondnum, E£, epjgastnum ; RU, umbilical region ; H, hypogastrium ; V, bladder. convexity disposed obliquely downward toward the left. It, with the cardia and pylorus, which it connects, lies more posteriorly, covered by the liver, while the greater curvature extends forward toward the abdominal wall, so that a line drawn from the lowest point of the lesser to the lowest point of the greater curvature would incline for- ward and downward. The situation of the greater curvature varies very much with the degree of distention of the stomach. In health, however, it only very exceptionally extends to the umbilicus. The fundus of the stomach is adjacent to the diaphragm, the spleen, and the left kidney; its greater curvature and also the lower part of its posterior surface to the transverse colon ; the pylorus, lesser curva- ture and that portion of its anterior surface which is near to these to- the left lobe of the liver. Behind and above the stomach, situated at the upper part of its posterior surface, is the sinus of the peritoneal cavity, the bursa omentalis (pathologically not unimportant), and also the pancreas. 2/0 SPECIAL DIAGNOSIS. When the stomach is moderately distended a part of the anterior surface and the greater curvature are parietal, so far as they are not prevented by the lung or heart from above, or by the spleen on the left, and by the left lobe of the liver on the right. That part of the parietal surface of the stomach which is covered by the left lower por- tion of the ribs comprises the important region to which Traube gave the name of " halfmoon-shaped space!' We see from this description that with moderate distention only a small part of the healthy stomach can be directly examined. The most important parts, the cardia and pylorus, are bent deeply in. But we have a favorable moment for examining the latter in certain pathological conditions, where it is desirable to be able to judge of it, it being often pushed down with the lesser curvature below the liver. Inspection and Palpation of the Stomach.—There is scarcely any place where inspection and palpation are so closely connected as at the abdomen, and especially the stomach. The patient is placed so as to lie comfortably, with the upper portion of the body moderately raised. We look at the region of the stomach with the greatest care, illuminating it from all possible directions: then palpate with the tips of the first, second, and third fingers, and thus notice first the tender- ness (always at first proceeding very cautiously), then the objective condition ; finally completing the palpation with inspection, or vice versa. The result of the two methods of examination will be affected by several factors—by the size, sharpness of the boundaries, and density (resistance) which we discover in the abdominal wall, and its condition. As regards the latter, it is important for the examiner to avoid causing contraction of the abdominal muscles by having the patient in the recumbent posture, cautioning him to keep the muscles lax, and by proceeding slowly with the palpation, the hands being warmed. Con- traction of the recti abdominales, with their short tumor-like sections of muscle, may very much disturb, or even deceive, one in making an examination. As to the general thickness of the abdominal walls in chronic diseases of the stomach, especially if very severe, this is very much lessened by wasting—a condition favorable for making an exam- ination. The normal stomach cannot at all distinctly be recognized or defined through the abdominal wall. It can only exceptionally be done when there is extreme emaciation. Not infrequently there are cases where, in extremely wasted females with very lax walls, the greater curvature and peristalsis of the anterior wall of the stomach could be clearly seen. In these cases the autopsy shows a normal condition of the stomach. On the other hand, the healthy stomach, distended with food or gas, sometimes enables us to imagine its condition by the projection in the epigastrium, and still more by a high halfmoon-shaped space—that is, by tympanitic resonance over the left lower lobe of the lung in the side.1 We can sharply bound a healthy stomach only in individual cases when it is inflated with gas.2 Thus, it has been found that the greater curvature of a normal stomach, when very greatly distended, 1 See under Percussion. 2 See Method of Procedure, p. 271. EXAMINATION OF THE DIGESTIVE APPARATUS. 271 may reach as far as the umbilicus. Of course we cannot ascertain the location of the lesser curvature if the stomach is in its normal position. Moreover, the distensibility of the healthy stomach varies very much with different persons, so that on trial one person earlier, and another later, has difficulty, especially oppression, which marks the limit of distention. The chief pathological signs furnished by the stomach are: its dis- tention or displacement, its thickness, and amount of peristaltic action of its walls, also signs of circumscribed tumors in its walls. Other important signs are to be added to those already mentioned. Pain upon pressure during palpation requires a special description. Distention is more or less distinctly made out by inspection and palpation, according to its extent and the thinness of the abdominal walls. But it may also entirely elude examination. In favorable cases we can see and feel (easily when looking down from the patient's head) the greater curvature. To a varying extent it moves down, often below the umbilicus, more rarely nearly to the symphysis, and in so doing it shows the bend toward the left. The position of the greater curvature of course varies with the degree of fulness of the stomach, but usually, unless artificially emptied,1 as by emesis or the stomach-pump, it does not come up above the umbilicus. At the same time the pyloric por- tion very often has a peculiar behavior which influences the whole sit- uation of the stomach and renders the pylorus as well as the lesser curvature accessible for examination. When the stomach, for the time being, is distended by a large quantity of food, in the upright position of the patient it pulls the pylorus forward from under the liver, and with it, under some circumstances, the lesser curvature. This, in rare cases, is seen in the upper epigastrium, in a line convex downward (when the light falls from the foot of the bed), when sometimes it may even be felt. Also the portio pylorica and even the normal pylorus may be felt.2 In consequence of this displacement of the pylorus the whole stomach slopes more strongly downward toward the right. In rare cases the pylorus has this low down position, without there being any dilatation of the stomach. The condition is congenital or caused by strong adhesions (Kussmaul). As has already been mentioned, the distinctness with which the figure of the stomach can be made out is largely influenced by the extent of its fulness. Hence, for the purpose of making the examina- tion we must artificially distend it (Frerichs). Until very recently this was always done with carbonic acid, by giving the patient as much as two teaspoonfuls of tartaric acid and bicarbonate of soda dissolved in a little water. The gas quickly develops in the stomach, and demon- strates clearly the situation and size of the organ, rendering the exami- nation of its walls easy.3 But this procedure sometimes gives rise to a feeling of oppression, and even of symptoms of collapse. Recently there has been devised a method of inflating the stomach which is much more to be recommended, because the amount of gas for distending the stomach can be regulated exactly, and, if necessary, it can be emptied out in an instant. A soft stomach-tube is introduced (just as in sound- 1 See under Contents of the Stomach. 2 See under Tumors. 3 See under Peristalsis and Hypertrophy. 272 SPECIAL DIAGNOSIS. ing the esophagus), and then the stomach is inflated with air through the tube by means of an India-rubber ball, introducing as much as is necessary or as the patient can bear. At any time the air can imme- diately be let out through the tube. By inflating the stomach the so-called hour-glass stomach can be easily recognized during life (twice it was formed by a scar which strictured it in the middle). In the same way we can discover that the pylorus does not close, by the fact that the gas blown in does not dis- tend the stomach, but immediately enters the small intestine. Von Ziemssen still gives the preference to distention with carbonic acid—a method which we will not omit to mention. In his last com- munication he gives the proportions for adult men as 7 grams of bicar- bonate of soda and 6 grams of tartaric acid; for adult women 1 gram less of each. The sound may be employed in the same way as with the esophagus to determine stenosis at the cardia due to cancer. (The employment of a hard English esophageal sound for ascertaining the size of the stomach [Leube] is scarcely to be recommended. The sound is intro- duced into the stomach, and pushed on until it meets resistance at the greater curvature, and then we ascertain where the end of the sound is by palpation from without.) Regarding palpation by striking and the resulting splashing, see under Auscultation. In the neighborhood of the stomach we may have epigastric pulsation,1 liver-pulse ;2 lastly, it may be communicated from the aorta or from aneurysm of the abdominal aorta. With tumors of the stomach the pulsation from the aorta is usually very distinctly transmitted. Increased resistance ; peristaltic motions. The former occurs simul- taneously with the general distention of the stomach in consequence of the hypertrophy of the muscular portion which generally accompanies dilatation of the stomach. Hence it is an indirect sign of dilatation. If it is found within a limited area, as in the right half of the epigastrium, even if it is not sharply defined it may indicate carcinoma. We must be careful not to confound it with contraction of one of the bellies of the rectus abdominis. Peristaltic motions which can be felt as well as seen are very important, being often the first signs of an hyper- trophy, and thus a dilatation. By their situation and extent they may also indicate the size of the stomach. It is very rare for them to occur without dilatation : only in nervous " peristaltic unrest" of the stomach (Kussmaul). Generally they extend in the normal direction from the fundus to the pyloric region. But sometimes, and that in marked pyloric stenosis, they are reversed—antiperistalsis. They will often be excited or increased by gentle strokes and by faradization ; sometimes by irritation of the skin, as by simply uncovering it. With very lean persons we must think of the possibility of there being, under some conditions, intestinal peristalsis. Tumors in the region of the stomach are often only to be felt, not seen. They cannot be demonstrated if connected with a part of the stomach that is not parietal—cardia, lesser curvature, posterior wall of the stomach, commencing cancer of the pylorus. These tumors are 1 See p. 177. 2 See pp. 221 and 228. EXAMINATION OF THE DIGESTIVE APPARATUS. most frequently cancer of the stomach (more rarely a dense scar from ulcer), and are most often located to the right of the middle line, because they belong to the portio pylorica or to the pylorus itself. In the latter case they can generally only be felt when the pylorus is pushed downward, as has already been mentioned. Carcinoma usually feels uneven and dense. Less frequently it is smooth, and can then easily be overlooked or be mistaken for a belly of the rectus.1 Pro- jection of the stomach during deep breathing, as a result of the move- ments of the diaphragm, usually does not take place at all, for the reason that the stomach is not a solid body. We observe a slight, or possibly a marked, respiratory displacement when there is adhesion of the distended pylorus and the liver,2 or if there is a tumor which extends from the subphrenic region to a parietal portion of the stom- ach. Dense scars from ulcers and the infrequent hypertrophy of the pylorus, also solid bodies that have been swallowed, may feel like tumors. Mistaking them for scybala in the transverse colon3 is not likely to happen. In all diseases of the stomach tenderness during palpation may be wanting. It is absent least frequently with ulcer of the stomach. If there is pain, it may vary very much: in acute catarrh of the stomach, also sometimes in chronic, it is dull and quite diffuse; with ulcer it is often very much circumscribed, limited to a spot the size of a dime, ex- tremely severe, often shooting through to the back, especially toward the left; in carcinoma there is sometimes a marked insensibility, sometimes a more diffuse, sometimes a narrowly-defined, pain of variable intensity. A constant circumscribed tenderness in the gastric region and se- vere spontaneous pain, which are markedly increased by movements of the body, according to the observations of Landerer, may also be produced by adhesions of the stomach or omentum to the abdominal wall. The cause of the adhesion in such cases is most probably a former ulcus ventriculi or a former circumscribed trauma. Such cases are very difficult to distinguish from nervous cardialgia or splanchnic neuralgia. Percussion of the Stomach.—This applies to that portion of the anterior wall of the stomach which lies against the abdomen and the anterior (left lower) wall of the thorax. It yields, in much the greater majority of cases, a very deep tympanitic sound, and sometimes, when there is marked tension of the stomach, a clear non-tympanitic sound. If the stomach contains a considerable amount of food, it may, in part (especially in standing), have an absolutely dull sound. But we hardly ever find it dull throughout the whole extent of that portion of the stomach that is parietal, because it almost always contains considerable gas as well as food. The tympanitic as well as the non-tympanitic stomach-sound frequently has a metallic quality. The boundaries of the stomach are determined by topographical per- cussion (see Fig. 103). They are as follows : On the side toward the liver there is a dull sound; it is often dif- ficult to make out because the border of the liver is thin.4 On the side toward the lung there is a non-tympanitic, clear sound. Here it is 1 See under Resistance. 2 See this. 3 See Intestine. 4 See Percussion of the Liver. 18 274 SPECIAL DIAGNOSIS. often difficult to mark sharply the boundary-line, on account of the thinness of the border of the lung and the similarity of the two sounds. Sometimes we have to distinguish a boundary of the stomach from the heart, should the apex of the latter reach farther toward the left than the liver; sometimes from the spleen if the stomach should be stretched out somewhat. We can separate it from the large and small intestines, both of which give a tympanitic sound. Except these last named the boundary-lines are all dependent upon the situation and size of the surrounding organs. Therefore, and because there are no true boundary-lines for the stomach, except its parietal boundaries, we do not employ percussion for the stomach. <~9^ I | 77, Fig. 103.—Percussion boundary of the lungs in front (Weil). g, h, the upper boundary of the lungs ; e,f, the lower boundary of the lungs ; b, d, boundary between the lung and heart at the incisura cardiaca. The darkly-hatched surface represents the portions of the heart and liver that are in contact with the chest-wall; the light hatching, the so-called relative heart- and liver-dead- ness (see later), tn, spleen-deadness ; «, the average position of the lower boundary of the stomach. The only real boundary is that on the side toward the intestine, which gives the situation of the greater curvature. But it is almost always very difficult to determine this line (there being a tympanitic sound on both sides of it, with only a difference in pitch). We can hardly even maintain its correctness without the aid of inspection and palpation. Thus, percussion of the stomach, for the great majority of cases, has an extremely doubtful value. On the whole, we get the best results from percussion in health, and particularly when the stomach has been artificially dilated. With the former we then find that the greater curvature usually is somewhat above the umbilicus, sometimes reaching beyond it. When the stom- ach is moderately full it commonly stands below the umbilicus, between the apex of the xiphoid process and the umbilicus. If the stomach is EXAMINATION OF THE DIGESTIVE APPARATUS. 275 dilated, the boundary is lower down.1 Likewise, should the lesser curvature be lower down, it can be made out by the aid of percussion. Another procedure, but one which is not always successful, is first to empty the stomach as much as possible,2 then to percuss the abdomen, the patient being in the standing position. Usually we do not find any boundary for the stomach. Then we have the patient drink freely, and again percuss while he is standing. In the lower part of the stomach, hence above the greater curvature, about in the middle line, we shall find a dulness which indicates the situation of the greater curvature, and thus a possible dilatation may be recognized (modified after Penzoldt). This dulness may sometimes be directly proved, without any preliminary procedure, if the stomach is partly filled with fluid. The dulness disappears when the patient lies down. There is distinct dulness with tumors of the stomach (strong per- cussion) only when they are very thick, and this is not often the case. Hence they usually give stomach-resonance. But tumors of the liver and spleen, on the other hand, almost always are dull because they are larger. Yet this difference is not an entirely sure sign. Rod-pie-ximeterpercussion^ over the stomach usually gives a beauti- ful silver tone. It is employed for determining the boundary under the supposition that in this way the person who is listening over the stom- ach must hear the high silver tone just so long as his assistant per- cusses over the stomach; but the result of this procedure is hardly ever positive enough to give it value. That part of the left lower lobe of the lung is designated as the "circular stomach-lung space" where a tympanitic sound may be heard with strong percussion (Ferber). We may likewise speak of a "circular stomach-liver space," sometimes even of a "stomach-heart space."4 None of these have any value for exactly determining the size of the stomach. The Halfmoon-shaped Space (Traube).—This is the name given to that portion of the lower left part of the thorax which lies below the lung (or heart), between the liver and spleen, and, as a rule, in health gives a tympanitic sound, most frequently a stomach-sound, but not infrequently also an intestinal sound, or both. It is discovered by gentle percussion. Occasionally, in health, we here find dulness instead of tympanites, and then only when the stomach is decidedly full, or when the full transverse colon is here parietal, or when the greater omentum is unusually loaded with fat (Weil). In enlargement of the liver, of the left heart, or of the spleen this space will always be found correspondingly smaller. But its behavior in certain conditions of the left lung or of the left pleura is of especial diagnostic interest. Exudation in the left pleura usually causes dulness correspondingly early in the upper portion of this space in that it first collects in the complementary pleural sinus. As the ex- udation increases, the halfmoon-shaped space diminishes more and more, the dulness sometimes extending as far as the bend of the ribs, depending upon the amount of downward pressure of the diaphragm, unless there are pleuritic adhesions in the pleural sinus, in which case 1 See Inspection, Palpation. 2 See Emesis. 3 See p. 117- 4 See p. 179. 276 SPECIAL DIAGNOSIS. we do not have the space diminished. As the pleuritic exudation is absorbed the space resumes its normal proportions, and if there is shrinking after the absorption, it becomes greater than normal, for the reason that the lower border of the lungs does not again come down to its former place, and, on the other hand, the diaphragm stands higher. Rarely, with pneumonia of the whole left lung or its lower lobe the halfmoon-shaped space becomes very slightly smaller as a result of the enlargement of the lung during hepatization, and also, probably, from a small pleuritic exudation. It is to be observed that in acute disease of the left half of the chest an early distinct diminution of the halfmoon-shaped space is made manifest by a certain degree of dulness ; a marked diminution of the space indicates, almost to a certainty, a pleuritic exudation ; and if there is extensive dulness in the left half of the chest, if the differential diagnosis between pneumonia and pleurisy is uncertain, then a decided diminution in the size of the space speaks with strong emphasis in favor of the latter. Auscultation of the Stomach.—This has value in only one direction, but that is not to be undervalued. When palpation is made by strokes upon the region of the stomach, striking more or less strongly, according to the sensibility of the patient, very short blows with the tips of the fingers, sometimes spontaneously, and again only with the strokes, we hear a splashing which is loud enough to be heard at a distance. This results from a certain relation between the fluid and the gas in the stomach even in health, but very much more frequently in dilatation. Hence in making a careful examination of the stomach we must always employ it. In itself it does not indicate any- thing, even though it is often found when the examination is frequently repeated. Such a splashing sound or a similar one may also have its origin in the intestines and even in the peritoneal cavity. As an intestinal sound it is heard in profuse diarrhea, most markedly in cholera; also some- times in intestinal occlusion. From the peritoneal cavity a somewhat similar sound may be heard in circumscribed perforating peritonitis, particularly in subphrenic abscess.1 If we apply the ear when the stomach is inflated with carbonic acid, we shall hear a loud seething. We can recognize the same thing, but less distinctly, in dilatation of the stomach with fermentation of its contents. Illumination of the Stomach; Gastro-diaphanoscopy.—The first method applicable in man by which an illuminating body, visible through the abdominal wall, could be introduced into the stomach, was devised by Einhorn in 1889. Einhorn's instrument is a stomach-tube which carries on its lower end an incandescent lamp surrounded by a glass shade. The conducting wires go through the interior of the hol- low sound. This illuminating sound can be introduced into the stom- ach like any other stomach-sound, and the illumination effected by turn- ing on the current without injury to the stomach, whether it be full or empty, for the amount of heat is very slight. The diagnostic results of diaphanoscopy are greatly heightened if a considerable quantity of 1 See this. EXAMINATION OF THE DIGESTIVE APPARATUS. 277 water (up to 1500 c.c.) is introduced before or during the examination This may be done with the illuminating sound itself if an aperture is made in it directly above the lamp (Kuttner). The illumination may bring into view a part of the greater curvature, and in gastroptosis also a part of the lesser, and also tumors located in the anterior wall may be perceived as dark places in the illuminated region. An important result of the method seems to be that the normal as well as the dilated stomach appears considerably larger if filled with water than has been hitherto supposed. Sources of error, as the illumination of neighboring intestinal coils filled with water and gas, it must be borne in mind, are not excluded. I have no personal experience with the method, and therefore re- specting the details refer to the writings of Kuttner1 and Meltzing.2 Whether diaphanoscopy really gives considerably better results than a carefully made examination of the stomach by inflation and percussion in a standing position certainly seems to me still doubtful, according to the results of these investigations. Remark.—It is evident from the above that very often anatomical diseases of the stomach exist without any physical signs. Conse- quently, their differential diagnosis from nervous cardialgias and from some forms of nervous dyspepsia is frequently very difficult. In general, a certain uniformity of stomach complaints and their increase by moderate exercise of the body points to an anatomical disease. Most frequently, however, a positive differential diagnosis can be made by an investigation of the functions of the stomach. Therefore the examination of the motive-power of the stomach during digestion and a chemical examination of its contents frequently give much more im- portant conclusions than the local examination. Therefore especial attention is called to the former. EXAMINATION OF THE INTESTINES. Inspection and Palpation.—In employing the former there must of course be illumination. The patient being in the dorsal posi- tion, we inspect the trunk, as a whole, from a distance; in detail, close at hand, palpating with a warm hand. Then, carefully grasping a part, we notice always first as to the amount of tenderness, when, if there is any suspicion of simulation or exaggeration, it is best not to ask whether we are causing pain, but simply to notice the result of moderate and also stronger pressure. After completing the first examination, which gives one the bearings of the case, inspection and palpation go, hand in hand, very closely together; for this reason we speak of them together. Pain Produced by Pressure ^Tenderness].—A diffuse dull pain often occurs with intestinal catarrh. A like diffuse, but generally an ex- tremely severe, pain is observed with acute general peritonitis. Cir- cumscribed tenderness is especially frequent in the right iliac fossa. It is often quite marked in abdominal typhus [typhoid fever], often more severe in intestinal tuberculosis, moderately severe in typhlitis and affec- tions of the vermiform appendix, in both of the last-named diseases 1 Berliner klin. Wochensch., 1893. 2 Zeitschr.f. klin. Med., Bd. 27. 278 SPECIAL DIAGNOSIS. generally (not always) in connection with other local signs.1 Pain in the left iliac fossa is connected with the descending colon (especially dysentery). Very circumscribed severe pain at shifting points may occur with a circumscribed affection of the small intestine, as invagina- tion 2 (intestinal tuberculosis). The seats of hernia require very espe- cial attention. (Works upon surgery are to be consulted regarding these.) It is to be further remarked that pain in the abdomen, according to its location, may come from any of the organs contained in its cavity, and also from its walls; from the anterior abdominal wall (abscess); pain in the iliac regions from the hollow of the sacrum (inflammation, tumors); pains in the same place and in the lumbar region from psoas abscess. The dimensions of the abdomen may be increased: by a layer of fat; by gas in the intestines (intestinal meteorism, tympanites), as it occurs continually, scarcely pathologically, after hearty eating, often with a large development of fat; but we may also have it in every variety of degree as a pathological condition: in acute and chronic catarrh of the intestine, intestinal stenosis, in acute and chronic perito- nitis, and in abdominal typhus [typhoid fever], where it is often of diagnostic value. According to the amount of distention the abdomen is more or less full, which changes its normal soft condition to one of marked resistance. When there is marked meteorism the liver and diaphragm are pressed upon, and by the latter the lungs and heart are pressed upward. In a case of typhus abdominalis [typhoid fever] I once saw an exten- sive inflammatory undermining of the abdominal wall, which very closely simulated meteorism by considerably distending the abdomen, which proved to be an abscess in the abdominal muscle. (For disten- tion of the abdomen with fluid or air in the peritoneal sac, see Peritoneum.) There may be circumscribed distention of the abdomen from a great variety of causes: most frequently from some condition in the peri- toneum.3 In chronically developing stenosis due to tumors or in acute incarceration it is produced in the intestines themselves; the piece of intestine immediately above the stenosis becomes distended. The cor- rect diagnosis of such a circumscribed inflated piece of intestine is of great clinical significance, and must be sought for in every possible way. The chief point is to take time for inspection and likewise for palpation, observing carefully whether the flatulent portion is completely at rest or whether there is peristalsis,4 whether the swelling changes its position in its entirety or not, or whether it is sometimes flatter or dis- appears altogether. Palpation and percussion give uncertain results; they may, however, particularly the former, sometimes serve to confirm what the eye has discovered. Diminished volume of the abdomen (drawing-in, sinking-in) results from an insufficient amount of nourishment from any cause (especially from diseases of the esophagus, pyloric stenosis, any cachexia—in short, from any disease that requires (or results in) restricted diet. Usually this condition is more especially manifested by the absence of 1 See below. 2 See Palpation. s Which see, and also the next page under Tumors. 4 See this. EXAMINATION OF THE DIGESTIVE APPARATUS. fat and wasting of the abdominal muscles. A particularly marked— the so-called " scaphoid drawing-in "—probably related to an active contraction of the abdominal muscles, occurs in meningitis, particularly basilar, and in lead-colic. Intestinal peristalsis exceptionally can be seen when the abdominal wall is very thin and lax. It occurs almost exclusively in women who have had children (particularly if there is a separation of the recti mus- cles). On account of its similarity, it is to be distinguished from what is described below as pathological peristalsis only by the absence of other phenomena and by the narrowness of the intestinal figure. Pathological peristalsis is an important visible and palpable sign of stenosis of the intestine, and occurs in the portion of intestine above the stenosis. We observe a round projection, with the slow motions of a worm, now disappearing and often immediately reappearing in a spot not far distant, so that we have the phenomenon of peristalsis. The intestine, as it becomes prominent, is moderately resistant and is often distinctly distended. [During the instant of greatest distention the prominence is more distinctly tympanitic] The resistance may become greater in chronic stenosis of the intestine with hypertrophy. Some- times the last swelling—that is, the one just above the point of stenosis —is the largest, and subsides with a loud cooing or bursting sound. This phenomenon may have a very great variety of manifestations, generally with a pressing, choking pain, and it may manifest itself under gentle blows, with faradization, or even by merely exposing the surface to the air. It is usually very difficult to draw any conclusion regarding the portion of the intestine involved by the location of the phenomenon or the direction of the peristalsis. On account of its thickness we are apt to mistake a dilated loop of small intestine for a portion of the colon. Circumscribed tumors of the intestine are always felt before they can be seen. They may be—I. Balls of feces, scybala, in the large intes- tine, often recognized by being arranged in a circular form, by their location (which is often deceptive), or by their retaining an indentation. Sometimes we are only able to be positive regarding their nature by their disappearance after free purgation. 2. Tumors of the intestine are either new formations, which are generally very firm, uneven, or they result from invagination of one portion of the small intestine into another or into the large intestine, which form round vermiform tumors. The former are entirely fixed, the latter may suddenly disappear. Both may be connected with signs of stenosis of the intestine. If they be- long to the small intestine, they usually more or less change their location. (For distinguishing these tumors from those of the other abdominal organs, of the peritoneum, and of the abdominal wall, see below. For inflammatory tumors of the intestine, perityphlitis, etc., see Peritoneum.) Tumors of the rectum1 cannot be recognized from the abdomen. Those at the point of union between the transverse and the descending colon are often recognized late because they lie concealed. They may easily be confounded with tumors of the spleen or with the kidneys.2 In this connection we must bear in mind the phenomena of stenosis. 1 For these, see below. * See these. 280 SPECIAL DIAGNOSIS. For peritoneal friction-sounds, see Peritoneum; for cooing sounds that can be felt, see Auscultation of the Intestine. Palpation of the Rectum.—The rectum must be examined with the finger if the movement of the bowels or the character of the stools indicates disease of this organ, or if disease in the neighborhood (as the wall of the true pelvis, the prostate, or the seminal vesicles in men, the uterus and its annexae in women) is suspected. In making the exam- ination we first obtain a view of the anus externally. The anus is to be examined for varices, changes in the mucous membrane, etc., and its neighborhood for signs of syphilis, rectal fistula, etc. Sometimes it is also necessary to obtain a thorough emptying of the bowel before- hand. The index finger is to be oiled, and introduced with the patient either lying on the side or back.1 When the rectal sound is employed in order to reach a stenosis beyond the reach of the finger, the greatest care is necessary. It is best to employ a sound open at the end, so as to throw in some lukewarm water by means of an irrigator—a pro- ceeding by which any obstruction to the passing of the sound may be gotten out of the way. Sometimes a large quantity of water is thus employed, as recommended by Hegar (see also the works upon surgery for the employment of the mirror in making the examination). Distending the descending colon by inflating it with air introduced from the anus through the sound, if carefully done, is not dangerous, and is very strongly recommended for determining the location of the colon with reference to other organs, tumors,2 the figure and con- dition of the colon itself. When there is a suspicion of a stomach- colon fistula, sometimes a positive diagnosis may be made by this method if it is noticed that the stomach unmistakably presses forward in connection with the colon. If this phenomenon is absent, a stomach- colon fistula cannot with certainty be excluded, because the passage of air from the colon into the stomach may be absent if the fistula be small or its orifice closes like a valve. Percussion of the Intestine.—Generally the intestine gives a tympanitic sound; with meteorism with great tension it may become clear, non-tympanitic. Over large intestinal loops and also over the stomach (with like tension) the sound is deeper than over narrow portions; over lax portions it is deeper than over those under strong tension. But we can hardly ever determine as to the width of any portion of intestine by the resonance, chiefly because of the influence of tension, which, for a single loop of intestine, we cannot at all con- trol. Hence we cannot with certainty determine by percussioi the boundary between the colon and small intestine, a dilatation above a stenosis from another portion, or intestine from the stomach. At most, we can only determine the boundary of the descending colon by artificially inflating it. (For determining by percussion the boundaries of the abdominal organs that do not contain air, see under the different ones.) Intestinal tumors do not always become so large as to give dulness. In per- cussing them we first press tolerably deeply with the finger used as a pleximeter, and if we do not find dulness, we press still deeper, in order 1 For examining during narcosis by introducing the whole hand, see works upon Surgery. 2 See Spleen, Kidneys. EXAMINATION OF THE DIGESTIVE APPARATUS. 281 that we may push aside any fold of intestine that may lie over the tumor (" deep percussion "—Weil). Auscultation of the Intestine.—Grumbling sounds and splash- ings, which may often be heard at a distance (Borborygmi), and are in themselves very troublesome (especially in women who have had chil- dren), do not have any further significance. A loud cooing is not with- out diagnostic value if it occurs at the close of an attack of pain like strangulation. Even if we cannot see any intestinal peristalsis, we must remember the possibility of stenosis of the intestine. Although formerly too much importance was attached to it, yet there is some diagnostic value in the cooing, which is more frequently felt than heard in the ileo-cecal region in typhoid fever (ileo-cecal gurgling). EXAMINATION OF THE PERITONEUM. Pathological conditions of the peritoneum are, in part, of such a character that they affect the outer layers, the coverings of the other abdominal viscera; hence possible anomalies of the peritoneum may be overlooked in the direct examination. Thus, very many diseases of other abdominal organs are combined with those of the peritoneum. This fact and the anatomical interrelations of the diaphragm and certain other organs make it very difficult to give a separate descrip- tion of its physical diagnosis. In what follows we mention what may be learned in peritoneal diseases by the separate methods of examina- tion, but we call attention to the point that the examiner ought to learn to give his attention to all the abdominal organs, by inspection, palpation, etc., at the same time. Inspection of the Abdomen.—In diseases of the peritoneum this may reveal distention of the abdomen, which may be quite considerable and quite like intestinal meteorism. Meteorismus peritonei—that is, escape of air into the abdominal cavity from the intestine or stomach —is a very serious condition which always results in peritonitis.1 There is general, though often unequal, distention when there is freely-movable fluid in the peritoneal cavity—ascites. Such a fluid effusion collects in the most dependent part of the abdominal cavity— first in the true pelvis; then, as the amount increases, it rises higher, reaching the abdominal wall, where its level may stand at different heights. The abdominal organs that contain air float upon the top of the fluid, so far as the peritoneal fold permits. In consequence of the increased internal pressure the abdomen is broader and the lower parts contain the fluid, while the small intestine, containing air, generally lies at the upper part and is in contact with the abdominal wall. But the fluid, since it is freely movable with every change of position of the body, always occupies the most dependent part, and, if the tension of the abdominal wall is not too great, there often results an unequal dis- tention of the abdomen which varies with the position of the body. In the dorsal position it is quite toward the sides; when lying upon the side it is over the inguinal and lumbar regions upon each side; while in the sitting posture it fills the dependent abdominal sides, the upper 1 See below. 282 SPECIAL DIAGNOSIS. portions being empty; and in standing, the lower part of the abdomen projects. If there is so large an effusion as to fill the abdomen very full, there is no change in the distention, and it is also more regular, like that we have with marked meteorism. (Regarding the high posi- tion of the diaphragm when there is distention of the abdomen, see Respiratory Organs and Liver.) If the skin is examined, when there is marked effusion it will not at all look as it usually does: on account of the tension it is smooth, shining, and shows, especially in the dependent parts, a peculiar bluish shimmer. When the tension is of long standing there are colorless streaks or striae which are formed in the skin by the continuous stretch- ing, as in the scars resulting from pregnancy, so called from their chief cause. The umbilicus may be obliterated or even project. In marked ascites the cutaneous veins of the abdomen are found enlarged, since as collateral veins they must take up the overflow of the intra-abdominal veins, which are compressed. Under some circumstances there may be edema of the legs from compression of the iliac veins. (Regarding the caput medusa? and the abdominal veins in general in cirrhosis of the liver, see under Liver.) Ascites that moves about generally results from transudation into the abdominal cavity from stasis, being rarely, except in the beginning of a disease, dependent upon inflammatory exudations. In the former case it is either a partial indication of general dropsy and connected with edema,1 or entirely the result of obstruction of the portal vein (cirrhosis of the liver, compression, and thrombosis of the vein). In the latter case it is a sign of peritonitis.2 Circumscribed distention of the abdomen where there has been little or no change in posture may be due to inflammatory fluid exudations, which are enclosed between adhesions of the intestine to itself or to the abdominal wall, or by any kind of tumor in the abdominal cavity ; and also by tumors or abscess in the abdominal wall itself. Circumscribed distention, with inflammatory redness, indicates a discharge outward of an abscess, either fecal or some other collection of pus in the abdominal cavity, or of the abdominal wall. In diseases of the peritoneum palpation gives very important signs: Pain exists in all inflammatory affections. It is usually very severe in acute peritonitis, sometimes so great that the slightest motion, or even the lightest covering upon the abdomen, cannot be borne. This sensi- bility is an important indication of peritonitis, especially in distinguish- ing the ordinary intestinal meteorism from peritoneal meteorism, some- times also in distinguishing inflammatory ascites from dropsical ascites. Circumscribed pain may indicate a circumscribed peritonitis, as it occurs more particularly over tumors, abscess of the stomach and intestine. In chronic peritonitis, especially in tuberculosis, sometimes there is entire absence of tenderness. Now and then in chronic peritonitis there is a general, more or less symmetrical, hardness of the abdominal wall; that is to say, it feels as if it were thickened. This is to be distinguished from the general increased resistance from tension due to marked distention of the abdomen from meteorism and ascites. Thus there is a marked differ- 1 See this. 2 See under Palpation, Percussion. EXAMINATION OF THE DIGESTIVE APPARATUS. 283 ence between the resistance of fluid and that of meteorism in a fold of intestine. The latter has more the feeling of an air-pillow, the former is more like a material substance. But we recognize fluid with much more certainty by the feeling of fluctuation, undulation. A hand is laid flat upon the surface of the abdomen, and then the abdominal wall is tapped lightly with one or two fingers, just as in direct percussion. If both hands are used, fluc- tuation is found in a place where there is an accumulation of fluid, and the stroke of the wave is felt with every tap of the fingers. In this way the presence of even a small amount of fluid in the abdominal cavity can be made out with great certainty. When there is great effusion under high pressure this sign may fail. On the other hand, we may be deceived in the case of persons who have a large accumulation of fat in the abdomen by the trembling of the layers of fat, and possibly also by the fat in the abdominal cavity, especially in the omentum. Very much increase of resistance, and thus an indistinct fluctuation, generally occurs when the peritoneal fluid is encysted. Circumscribed hard resistance, now like a round ball and again cord- like, occurs with extremely great variations in chronic peritonitis, not alone of the tubercular variety, but also in the so-called simple perito- nitis from inflammatory new formations ; nevertheless, the former is usually the much more frequent condition. Particularly often in this, although sometimes also in simple chronic peritonitis, we feel above the navel a dense transverse string: the omentum is shrunken and thick- ened by inflammatory products. Besides, there are usually, but not always, the signs of encysted, or even of free, fluid in the peritoneal cavity. Exactly the same phenomena are present in carcinoma and sarcoma of the peritoneum. There occurs in an acute way resistance in the neighborhood of the cecum in typhlitis and perityphlitis. Here there is generally a circum- scribed globular or flattened globular tumor, usually immovable, which, at first at least, is extremely tender. It indicates a fixed mass of feces in the cecum or an inflammatory deposit upon the serous side of the cecum, or both. In inflammatory cases there remains for a long time, or even permanently after recovery, a dense spot (a scar from shrunken inflammatory new formation in the peritoneum). In inflammation of the vermiform appendix we can seldom affirm that there is a tumor. Palpation of the peritoneum through the vagina in order to discover whether there are tumors, exudations in Douglas's space and anywhere in the neighborhood of the uterus, especially the different forms of peritonitis, belongs to gynecology. Measuring the Circumference of the Abdomen.—It is not necessary to measure the circumference of the abdomen for establishing a diag- nosis, but yet it is valuable for the purpose of observing the course of an abdominal affection, and particularly for ascertaining the increase and diminution of fluid exudations. It is generally sufficient to meas- ure the abdominal circumference across the navel and the lower lumbar vertebrae. It is better also to measure the distance between the xiphoid process and the symphysis pubis. Percussion gives valuable information regarding the peritoneum as 284 SPECIAL DIAGNOSIS. to whether there is fluid effusion in the peritoneal cavity, its location and nature. By percussing with some force at what we suppose to be the boundary-line we can easily determine the boundary between the dulness of fluid and the tympanitic resonance of the intestine, but we can never distinguish it from that of those organs that do not contain air, as the liver, spleen, etc. The superior surface of a freely-movable effusion is always horizontal, and hence its upper boundary-line must correspond to a section of a horizontal plane drawn through the abdo- men in whatever position the patient may assume. Whenever the patient changes his position, the effusion immediately changes its rela- tions to the abdominal cavity.1 Hence the result of percussion changes with the position of the body: if the patient lies upon the right side, then the portion of the abdomen which is now lowest gives a deadened sound, the upper boundary of which is horizontal; in the left half of the cavity there is tympanitic resonance; if the patient turns upon the left side, this is now dull and the right is tympanitic. This is an important sign, not only that the fluid is movable, but often that there is fluid present. Small effusions, which rarely rise only a little above the pelvis, will hence be first recognized by percussing when the patient stands upright. If there is then dulness above the symphysis pubis, it immediately disappears when the patient lies upon the back. Very large effusions may fill the abdomen so full that the intestines, on account of a short mesentery, cannot float, and hence cannot come in contact with the abdominal wall. Then the strongly-distended abdo- men gives a dull sound throughout, and we sometimes notice a change of the boundary of dulness only in the position on the side, when the upper portion gives a clear sound. When the fluid moves about with difficulty, slowly and incompletely changing its location with the change of position of the body, and still more if it is entirely immovable, inflammatory exudation with gluing or adhesion of the intestines together and to the abdominal wall is indicated. If the fluid does not move, it is said to be encysted. But not infrequently even inflammatory exudation, at least in the beginning of its effusion, is freely movable. According to F. Miiller, 200 c.c. of ascitic fluid can be demonstrated with certainty in children, while with 150 c.c. there is uncertainty, and IOO c.c. cannot be recognized at all. In adults only 2000 c.c. give dis- tinct dulness, which changes with change of position, whilst with 1000 c.c. of liquid the result is doubtful. Percussion may be an important aid in recognizing meteorismus peritonei, in so far that in many cases, if adhesions have not already been formed before the occurrence of perforation, it gives a perfectly uniform tympanitic or, if the tension is great, a non-tympanitic, sound over the whole abdomen, also over the region of the liver and spleen, and, besides, on account of the diaphragm being arched greatly, as far as the fifth, or even the fourth, rib. Not infrequently in this way we obtain Heubner's rod-pleximeter phenomenon [see page 117]. Subphrenic peritonitis, pyopneumothorax subphrenicus (Leyden), subphrenic abscess. We understand by this an ichorous-purulent, sacculated peritonitis below the diaphragm. From paralysis the dia- 1 See above, under Inspection. EXAMINATION OF THE DIGESTIVE APPARATUS. 285 phragm is pushed very high into the thorax, causing a marked retrac- tion or compression of the lung of that side. That half of the thorax is broadened, and by the presence of pus and gas in the cavity one is apt to mistake the condition for pyopneumothorax. Peritonitis of this character usually begins at the stomach as an ulcer, or at the intestine, especially at the vermiform appendix and cecum. In making a dif- ferential diagnosis we observe whether, in the status prasens or in the previous development, there were indications of disease of the lungs or, on the other hand, of the abdomen, and also whether the lung of the diseased side still performs the motions of respiration. During puncture it has frequently been found that during inspiration the press- ure in a subphrenic cavity rises, while it falls, of course, in a pleural cavity. This can be recognized by the varying rapidity of discharge from the aperture made by the needle or by introducing a manometer into the cavity. The presence of air which has escaped into the peritoneal cavity is shown in many cases by the clear, metallic ringing, intestinal sound in the upper part of the abdominal cavity, sometimes even a metallic, transmitted breathing sound which it yields to auscultation. More- over, with the inflammatory deposits upon the reduplications of the peritoneum, especially over the liver and spleen, there occurs syn- chronously with breathing a peritoneal friction-sound exactly corre- sponding to the pleuritic friction-sound. It is very rarely produced by peristalsis over the intestines. If the friction-sound is pronounced, it can also be felt. When it is advisable, as a therapeutic measure, to draw off fluid from the peritoneal cavity by puncture, it maybe of diagnostic value in two ways: 1. It is then possible to examine the organs in the abdominal cavity which previously were concealed by the ascites. Not only does the fluid prevent the examination of the organs more or less completely covered by it, but the folds of the intestine floating upon it also do so, in that they crowd in between certain parts, especially the liver and spleen and the anterior abdominal wall. When the abdomen has been emptied, its wall, which before was tensely stretched, is very lax, and this renders the examination extremely easy. Hence we can now usually very easily discover the diseases which caused the effusion (cirrhosis of the liver, tumors, which press upon the portal vein, cancer of the stomach, ovarian tumor, etc.), or certain results of peri- tonitis (bands of scar-tissue which compress the intestine, swollen mesentery, etc.). 2. The fluid that has been drawn off can be examined. It is as important to do this as to examine pleural fluid.1 The ordinary hypodermatic syringe, having a thinner and larger cannula, holding 1 gram—not the larger one recommended for punct- uring the pleura—is to be employed for puncturing the abdomen. The place of puncture, the syringe, and cannula are to be carefully disinfected before the operation. In selecting a place to puncture it is necessary to be careful to avoid the stomach and intestines, particularly when they are not 1 Which see, p. \^>,ff- 286 SPECIAL DIAGNOSIS. adherent to the abdominal wall. It is true that experience teaches that even in puncturing a free coil of intestine there is scarcely any risk, but still precaution cannot do any harm. An exploratory punct- ure is principally required where the question concerns the distinction of solid tumors from those containing liquid or from capsulated liquid exudates, or where we wish to learn something of the nature of a fluid accumulation. In all such cases we have to do with places that are dull on percussion, therefore where, a priori, the danger of punctur- ing the intestines is not great. Nevertheless, a puncture of the intes- tine may easily be made, even where superficial and deep percussion has given a dull sound. Therefore, in general, it is more desirable to refrain from puncture in the abdominal than in the pleural cavity. Frequently the principal interest one has in an exploratory punct- ure is that we wish to make certain about the possible presence of pus; and pus enclosed in indurations generally causes the greatest difficulty. The most frequent case of this kind is to determine a perityphlitic abscess. Here there is usually a moderately thick induration, and to explore it is really a puncture in the dark. A puncture of the intestine in such a case will scarcely have very critical consequences ; but it is of more moment to have opened into the free abdominal cavity a road for the pus through a thin spot of fibrous adhesion. Thus it has hap- pened that the exploratory puncture has not revealed an actual abscess, or it may show pus, but not clearly indicate its relation to the appendix and cecum. For this reason some do not employ exploratory punct- ure here. At all events, we advise always to make it with a fine cannula only. As for the examination of the exudate which has been withdrawn, it is in all respects the same as that of the pleural fluids.1 Besides strepto- and staphylococci as exciters of acute peritonitis, there are also to be considered, above all, the bacterium coli commune. In chronic peritonitis it is of supreme interest to decide whether it may not be tuberculous in its nature. Microscopical examination of the exudate and of sedimented or sterile filtrated exudate has almost no value at all, while culture or vaccination also has scarcely any. Usually nothing but an exploratory laparotomy, removing a small piece of induration, and vaccinating a guinea-pig, settles the question whether there is tuber- culosis or not. However, this question is often decided indirectly—i. e. by the presence of other tuberculous diseases, as pulmonary, pleural, glandular, or genital tuberculosis. Chylous ascites has been observed in some cases of compression of the thoracic duct; the ascitic fluid is, to a varying extent, milk-like in appearance. It contains molecules of fat and a ferment that forms sugar. EXAMINATION OF THE LIVER. Anatomy.—The liver, covered by the peritoneum, lies close to the diaphragm—within its arch—and is held in place by the suspensory ligament and by the intra-abdominal pressure exerted upon its lower surface. About three-fourths of it is in the right side of the body, and 1 Compare p. 136,^". EXAMINATION OF THE DIGESTIVE APPARATUS. 287 one-fourth in the left. With reference to its superficial topography, a larger portion of it belongs to the right hypochondrium, extending into the epigastrium, with a small portion into the left hypochondrium. Usually it does not extend so far to the left as the apex of the heart. FlG. 104.—Location of the thoracic contents, of the stomach, and of the liver, from in front (Weil-Luschka). The unbroken hatched lines represent the portions of the heart and liver that are in contact with the thoracic wall. The portions of these organs that are not in parietal contact and are covered by the lungs are represented by the light hatching: e/(----), border of the right lung ; g h (----), border of the left lung; a b and c d (. . . .), boundary of the complementary pleural sinus ; L boundary between the upper and middle lobes of the right lung; k, boundary between the middle and lower lobes ; /, boundary between the upper and lower lobes of the left lung; w, stomach (greater curvature). Above, the lungs and heart glide over it, and it glides over the stomach (see Fig. 104). The extent to which its surface is in contact with the thoracic wall is determined by the relation of its upper surface to the diaphragm. Hence during expiration it rises in the right half of the body as high as the fourth intercostal space, and with its extreme left end to the fifth rib. The lower border, in the scapular and middle axillary line, stands about at the eleventh rib in the mammillary line, just at the border of the ribs, then proceeds obliquely upward toward the left, through the epigastrium, under the left border of the ribs, and almost to the apex of the heart. In the middle line, it stands about midway between the xiphoid process and the umbilicus. The gall-bladder lies just where the lower border of the liver passes under the right border of the ribs, hence close within the right mammillary line. The organs that border upon the liver are the lungs, the heart, and the diaphragm above, and the right kidney, colon, and stomach below. That portion of its upper convex surface which is not covered by the lungs or heart is parietal. This parietal portion is very small behind. 288 SPECIAL DIAGNOSIS. As it comes forward it is much broader, and is, for the most part, covered by the chest-wall, except in the epigastrium, where it is free from its bony covering. With children the liver is proportionately larger in all dimensions, so that its lower border is in the axillary line below the border of the ribs. Normally, the liver, strictly speaking, only moves in connection with the diaphragm. Inspection of the I